Provider Demographics
NPI:1134133960
Name:FREESTONE, BRADLEY DALLAS (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DALLAS
Last Name:FREESTONE
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 1:500 FOOTHILL DR
Mailing Address - Street 2:117LV
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84148-0001
Mailing Address - Country:US
Mailing Address - Phone:801-582-1565
Mailing Address - Fax:801-588-5817
Practice Address - Street 1:500 FOOTHILL DR
Practice Address - Street 2:117LV
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84148-0001
Practice Address - Country:US
Practice Address - Phone:801-582-1565
Practice Address - Fax:801-588-5817
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6255330-8908152W00000X
UT6255330-9934152WL0500X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD7028Medicaid
000060003Medicare PIN