Provider Demographics
NPI:1457767253
Name:BADARACCO, DERRICK
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:BADARACCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3217 MILLGATE CT
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-7629
Mailing Address - Country:US
Mailing Address - Phone:724-799-1387
Mailing Address - Fax:
Practice Address - Street 1:3290 BUFORD DR
Practice Address - Street 2:SUITE B-2
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-4928
Practice Address - Country:US
Practice Address - Phone:724-799-1387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002352152W00000X
GAGA 2860152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist