Provider Demographics
NPI:1144229394
Name:LIGHTFOOT, BRADLEY J (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:J
Last Name:LIGHTFOOT
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:PO BOX 1506
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0409
Mailing Address - Country:US
Mailing Address - Phone:360-242-3008
Mailing Address - Fax:360-807-7687
Practice Address - Street 1:2606 116TH AVE NE STE 100
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-1422
Practice Address - Country:US
Practice Address - Phone:425-462-7664
Practice Address - Fax:425-462-6429
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAT2798152W00000X
AKOPTT308152W00000X
WAOD00003839152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1144229394Medicaid
AK1023294Medicaid
WA2028348Medicaid
WAAB38248Medicare ID - Type UnspecifiedSEATTLE CLINIC