Provider Demographics
NPI:1902081177
Name:BRADLEY, DAVID B (OPTOMETRIST)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:B
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 HARRELL DR
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:GA
Mailing Address - Zip Code:31408-2005
Mailing Address - Country:US
Mailing Address - Phone:912-964-0483
Mailing Address - Fax:912-964-0488
Practice Address - Street 1:22 HARRELL DR
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:GA
Practice Address - Zip Code:31408-2005
Practice Address - Country:US
Practice Address - Phone:912-964-0483
Practice Address - Fax:912-964-0488
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-07
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000730152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U22498Medicare UPIN
55318854SAMedicare PIN