Provider Demographics
NPI:1003154915
Name:BRADLEY A. SHAFFER, O.D., P.C.
Entity Type:Organization
Organization Name:BRADLEY A. SHAFFER, O.D., P.C.
Other - Org Name:EYES ON SODDY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:SHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:423-779-7712
Mailing Address - Street 1:PO BOX 505
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:TN
Mailing Address - Zip Code:37321-0505
Mailing Address - Country:US
Mailing Address - Phone:423-779-7712
Mailing Address - Fax:
Practice Address - Street 1:106C KAREN DR
Practice Address - Street 2:
Practice Address - City:SODDY DAISY
Practice Address - State:TN
Practice Address - Zip Code:37379-4337
Practice Address - Country:US
Practice Address - Phone:423-834-9020
Practice Address - Fax:423-834-9021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-28
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN2767152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
103G702419Medicare PIN