Provider Demographics
NPI:1720160922
Name:JEFFERIES, BRYAN G (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:G
Last Name:JEFFERIES
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 1:2480 WINDY HILL RD SE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8644
Mailing Address - Country:US
Mailing Address - Phone:678-262-4220
Mailing Address - Fax:678-262-4221
Practice Address - Street 1:2480 WINDY HILL RD SE
Practice Address - Street 2:SUITE 400
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8644
Practice Address - Country:US
Practice Address - Phone:678-262-4220
Practice Address - Fax:678-262-4221
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057122207W00000X
NC2008-01722207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC151MJOtherBLUE CROSS OF NC
GA901559898AMedicaid
I51673Medicare UPIN
GA901559898AMedicaid
18BDGNJMedicare ID - Type Unspecified
NC1577Medicare PIN