Provider Demographics
NPI:1922149848
Name:WALLENTINE, BRETT (MD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:WALLENTINE
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 2628
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-2628
Mailing Address - Country:US
Mailing Address - Phone:706-364-5500
Mailing Address - Fax:706-364-6863
Practice Address - Street 1:800 OAKHURST DR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3650
Practice Address - Country:US
Practice Address - Phone:706-364-5500
Practice Address - Fax:706-364-6863
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046334207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08BBWRQMedicare PIN
GA4524Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
GAH53396Medicare UPIN