Healthcare Provider Details

I. General information

NPI: 1982093563
Provider Name (Legal Business Name): RONALD A. BRAKE,O.D.,P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2015
Last Update Date: 01/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 COLISEUM DR SUITE B
WINSTON SALEM NC
27106-5310
US

IV. Provider business mailing address

3505 BURNLEY DR
CLEMMONS NC
27012-8632
US

V. Phone/Fax

Practice location:
  • Phone: 336-397-0768
  • Fax:
Mailing address:
  • Phone: 336-766-6680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1384
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number1384
License Number StateNC

VIII. Authorized Official

Name: DR. RONALD ALLEN BRAKE
Title or Position: PRESIDENT
Credential: O.D.
Phone: 336-766-6680