Provider Demographics
NPI:1073500476
Name:MAIER, BRADLEY
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:MAIER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20669 BOND RD NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-6525
Mailing Address - Country:US
Mailing Address - Phone:360-779-2020
Mailing Address - Fax:360-779-3093
Practice Address - Street 1:2029 E SIMS WAY
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-6905
Practice Address - Country:US
Practice Address - Phone:360-385-5386
Practice Address - Fax:360-385-3863
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADD00001098152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2022382Medicaid
WA2022382Medicaid
WAAB06325Medicare ID - Type Unspecified