Basic Information
| Provider Information | |||||||||
| NPI: | 1194702225 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BREWER | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | HOWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 8667954020 | ||||||||
| Practice Location | |||||||||
| Address1: | 2215 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | WAYCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315010983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9122852021 | ||||||||
| FaxNumber: | 9122852558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 02/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT002187 | GA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 867974975C | 05 | GA | MEDICAID | 867974975A | 05 | GA | MEDICAID |