Provider Demographics
NPI:1841604220
Name:BROOME, MICHAEL WESLEY (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WESLEY
Last Name:BROOME
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 1:510 N BELAIR RD
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3105
Mailing Address - Country:US
Mailing Address - Phone:706-863-3030
Mailing Address - Fax:706-863-0093
Practice Address - Street 1:510 N BELAIR RD
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3105
Practice Address - Country:US
Practice Address - Phone:706-863-3030
Practice Address - Fax:706-863-0093
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002823152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist