Healthcare Provider Details

I. General information

NPI: 1679626543
Provider Name (Legal Business Name): JAMES BRENT BROWN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 01/10/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S DAWSON ST STE B
LAGRANGE GA
30241-3301
US

IV. Provider business mailing address

101 S DAWSON ST STE B
LAGRANGE GA
30241-3301
US

V. Phone/Fax

Practice location:
  • Phone: 170-688-5061
  • Fax: 706-885-9129
Mailing address:
  • Phone: 170-688-5061
  • Fax: 706-885-9129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT2100
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: