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General NPI Number Information
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NPI Number | 1457767253
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Entity Type | Individual
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Provider Name | DERRICK BADARACCO
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Gender | Male
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Dates
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Enumeration Date | 07/01/2014
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Last Update Date | 10/16/2024
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Provider Practice Location Address
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Address Line | 3290 BUFORD DR SUITE B-2
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City | BUFORD
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State | GA
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Zip | 30519-4928
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Country | US
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Telephone | 724-799-1387
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Fax |
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Provider Business Mailing Address
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Address Line | 4180 BUTLER DR
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City | CHAMBLEE
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State | GA
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Zip | 30341-1361
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Country | US
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Telephone | 724-799-1387
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 0618002352
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | GA 2860
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License Number State | GA
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