Provider Demographics
NPI:1316014715
Name:BRANDENBURG, KIMBERLY KAYE (OD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:KAYE
Last Name:BRANDENBURG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:KAYE
Other - Last Name:SHORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1762 COUNTRY WOOD DR
Mailing Address - Street 2:
Mailing Address - City:HOSCHTON
Mailing Address - State:GA
Mailing Address - Zip Code:30548-1791
Mailing Address - Country:US
Mailing Address - Phone:301-330-4265
Mailing Address - Fax:301-977-5101
Practice Address - Street 1:3331 HAMILTON MILL RD
Practice Address - Street 2:STE 1100
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-4096
Practice Address - Country:US
Practice Address - Phone:770-271-3500
Practice Address - Fax:770-271-0805
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1144152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD916573Medicaid