Provider Demographics
NPI:1194835397
Name:BRADLEY, ELLEN ROBERTA (OD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:ROBERTA
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:GARFIELD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11714 SE FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:HOBE SOUND
Mailing Address - State:FL
Mailing Address - Zip Code:33455-5303
Mailing Address - Country:US
Mailing Address - Phone:772-546-4116
Mailing Address - Fax:772-546-5172
Practice Address - Street 1:11714 S FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:HOBE SOUND
Practice Address - State:FL
Practice Address - Zip Code:33455-5303
Practice Address - Country:US
Practice Address - Phone:772-546-4116
Practice Address - Fax:772-546-5172
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1904152W00000X
VA061001178152W00000X
NJONO4493152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19963Medicare PIN
FL0938670001Medicare NSC
FLT93934Medicare UPIN