Healthcare Provider Details

I. General information

NPI: 1851394969
Provider Name (Legal Business Name): CARLA S. BRANCH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 09/17/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

658 NORTHSIDE DR E STE A
STATESBORO GA
30458-4828
US

IV. Provider business mailing address

658 NORTHSIDE DR E STE A
STATESBORO GA
30458-4828
US

V. Phone/Fax

Practice location:
  • Phone: 912-764-9684
  • Fax: 912-489-8676
Mailing address:
  • Phone: 912-764-9684
  • Fax: 912-489-8676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number029847
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: