Provider Demographics
NPI:1982093563
Name:RONALD A. BRAKE,O.D.,P.A.
Entity Type:Organization
Organization Name:RONALD A. BRAKE,O.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:336-766-6680
Mailing Address - Street 1:3505 BURNLEY DR
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8632
Mailing Address - Country:US
Mailing Address - Phone:336-766-6680
Mailing Address - Fax:
Practice Address - Street 1:611 COLISEUM DR
Practice Address - Street 2:SUITE B
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-5310
Practice Address - Country:US
Practice Address - Phone:336-397-0768
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1384152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1174747851Medicaid
NC1174747851Medicaid