Provider Demographics
NPI:1174747851
Name:BRAKE, RONALD ALLEN (OD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:ALLEN
Last Name:BRAKE
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 1:3505 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 1:4424 W WENDOVER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-2600
Practice Address - Country:US
Practice Address - Phone:336-218-1188
Practice Address - Fax:336-292-3167
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1384152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCU13565Medicare UPIN
NC2467520DMedicare ID - Type Unspecified