Provider Demographics
NPI:1033371729
Name:BRADLEY, JONATHAN R (OD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:R
Last Name:BRADLEY
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 1:4837 E RTE 36
Mailing Address - Street 2:CENTRAL ILLINOIS VISION CENTER
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-9725
Mailing Address - Country:US
Mailing Address - Phone:217-864-1362
Mailing Address - Fax:217-864-1363
Practice Address - Street 1:4837 E RT 36
Practice Address - Street 2:CENTRAL ILLINOIS VISION CENTER
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521
Practice Address - Country:US
Practice Address - Phone:217-864-1362
Practice Address - Fax:217-864-1363
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003512A152W00000X
IL046010255152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200904330Medicaid
IN546000HHHMedicare PIN
IN232530QMedicare PIN
IN544150HHHHMedicare PIN
IN825700QQQMedicare PIN