Provider Demographics
NPI:1649253410
Name:BROWN, LARRY RAY (OD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:RAY
Last Name:BROWN
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 1:101 MARKET PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30121-2236
Mailing Address - Country:US
Mailing Address - Phone:770-386-9022
Mailing Address - Fax:770-382-3188
Practice Address - Street 1:101 MARKET PLACE BLVD
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30121-2236
Practice Address - Country:US
Practice Address - Phone:770-386-9022
Practice Address - Fax:770-382-3188
Is Sole Proprietor?:No
Enumeration Date:2005-11-24
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1436152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00787355AMedicaid
GA41ZCCTFMedicare PIN
GAU25548Medicare UPIN