Provider Demographics
NPI:1821022443
Name:BRUMBERG, JACK BENJAMIN (OD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:BENJAMIN
Last Name:BRUMBERG
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 1:1030 13TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-2240
Mailing Address - Country:US
Mailing Address - Phone:706-327-3937
Mailing Address - Fax:706-596-6658
Practice Address - Street 1:1030 13TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2240
Practice Address - Country:US
Practice Address - Phone:706-327-3937
Practice Address - Fax:706-596-6658
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000993152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAT84001Medicare UPIN
GA19532ZMedicare ID - Type Unspecified