Provider Demographics
NPI:1265441315
Name:BRACK, LAWRENCE F III (MD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:F
Last Name:BRACK
Suffix:III
Gender:M
Credentials:MD
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Mailing Address - Street 1:5900 HILLANDALE DR
Mailing Address - Street 2:SUITE 345
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-3802
Mailing Address - Country:US
Mailing Address - Phone:770-987-0733
Mailing Address - Fax:770-987-3978
Practice Address - Street 1:5900 HILLANDALE DR
Practice Address - Street 2:SUITE 345
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-3802
Practice Address - Country:US
Practice Address - Phone:770-987-0733
Practice Address - Fax:770-987-3978
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2014-06-13
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Provider Licenses
StateLicense IDTaxonomies
GA047403207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000898422CMedicaid
GA000898422CMedicaid
GAH09713Medicare UPIN