Provider Demographics
NPI:1467454272
Name:BRAUTIGAM, DARRELL LAWRENCE (OD)
Entity Type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:LAWRENCE
Last Name:BRAUTIGAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5848 HOWELL HIGHLANDS PL
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-1843
Mailing Address - Country:US
Mailing Address - Phone:770-921-8333
Mailing Address - Fax:
Practice Address - Street 1:7175 JONESBORO RD
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-2943
Practice Address - Country:US
Practice Address - Phone:770-961-2020
Practice Address - Fax:770-968-0854
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA683T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA55000122AMedicaid
GAU22207Medicare UPIN
GA55317054SAMedicare ID - Type Unspecified