Provider Demographics
NPI:1750446506
Name:BEARDEN, BROOK GOFF (MD)
Entity Type:Individual
Prefix:DR
First Name:BROOK
Middle Name:GOFF
Last Name:BEARDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:706-494-3008
Practice Address - Street 1:4340 KINGS WAY
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-6921
Practice Address - Country:US
Practice Address - Phone:229-333-9736
Practice Address - Fax:229-333-0225
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA56527207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00355787OtherRAILROAD MEDICARE
GA420420515AMedicaid
GA$$$$$$$$$OtherTRICARE
GAP00355787OtherRAILROAD MEDICARE