Basic Information
| Provider Information | |||||||||
| NPI: | 1790779254 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WARREN | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | BLAIR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6035 FAIRVIEW RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282103256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953000 | ||||||||
| FaxNumber: | 7048388494 | ||||||||
| Practice Location | |||||||||
| Address1: | 646 HARTNESS RD | ||||||||
| Address2: | |||||||||
| City: | STATESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286773423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048724108 | ||||||||
| FaxNumber: | 7048736517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2005 | ||||||||
| LastUpdateDate: | 04/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 200301426 | NC | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 2407151 | 01 | NC | UNITED HEALTHCARE | OTHER | 136WP | 01 | NC | BCBSNC | OTHER | 000000295044 | 01 | SC | UNISON HEALTH PLAN SC | OTHER | 188941 | 01 | NC | MEDCOST | OTHER | 7833504 | 01 | AETNA | OTHER | P00292839 | 01 | RAILROAD MEDICARE | OTHER | G0142B | 05 | SC | MEDICAID | 81900 | 01 | SC | CHCARES OF SC | OTHER | 20096157 | 01 | SC | SELECT HEALTH OF SC | OTHER | 89136WP | 05 | NC | MEDICAID |