Provider Demographics
NPI:1790897494
Name:BROWN, GLENDA B (OD)
Entity Type:Individual
Prefix:DR
First Name:GLENDA
Middle Name:B
Last Name:BROWN
Suffix:
Gender:F
Credentials:OD
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Mailing Address - Street 1:1120 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-2013
Mailing Address - Country:US
Mailing Address - Phone:770-809-3366
Mailing Address - Fax:770-809-3367
Practice Address - Street 1:1120 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:STE 101
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-2013
Practice Address - Country:US
Practice Address - Phone:770-809-3366
Practice Address - Fax:770-809-3367
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA001006152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U22212Medicare UPIN
GAGRP2583Medicare PIN