Provider Demographics
NPI:1942396452
Name:ENGRAM, IBRY DELL (OD)
Entity Type:Individual
Prefix:DR
First Name:IBRY
Middle Name:DELL
Last Name:ENGRAM
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:P.O. 160
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214
Mailing Address - Country:US
Mailing Address - Phone:706-782-6961
Mailing Address - Fax:706-782-6966
Practice Address - Street 1:1455 HWY 441 SOUTH
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525
Practice Address - Country:US
Practice Address - Phone:706-782-6961
Practice Address - Fax:706-782-6966
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000655152W00000X
SC1398152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00057967AMedicaid
25977OtherAVESIS
NC89093NTMedicaid
GA41ZCDRBMedicare ID - Type Unspecified
NC89093NTMedicaid