Provider Demographics
NPI:1912221755
Name:DEGEORGE, BRENT R (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:R
Last Name:DEGEORGE
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 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 JEFFERSON PARK AVE FOURTH FL
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0136
Practice Address - Country:US
Practice Address - Phone:404-924-5078
Practice Address - Fax:434-924-8118
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101262506208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program