Provider Demographics
NPI:1073726022
Name:BRADSHAW OPTOMETRY
Entity Type:Organization
Organization Name:BRADSHAW OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:K
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:916-682-5558
Mailing Address - Street 1:8829 SHELDON RD STE 150
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-5045
Mailing Address - Country:US
Mailing Address - Phone:916-682-5558
Mailing Address - Fax:916-688-5569
Practice Address - Street 1:8829 SHELDON RD STE 150
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-5045
Practice Address - Country:US
Practice Address - Phone:916-682-5558
Practice Address - Fax:916-688-5569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10618T305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA19222OtherSPECTERA
CASD0106180Medicaid
CA14460OtherMEDICAL EYE SERVICES
CAEYEMEDOther118210
CA=========OtherBLUE CROSS OF CALIF.
CAEYEMEDOther118210
CASD0106180Medicaid
CA=========OtherBLUE CROSS OF CALIF.
CASD0106180Medicare ID - Type Unspecified