Provider Demographics
NPI:1225077076
Name:ANDERSON, BRADLEY (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:ANDERSON
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 1:757 45TH AVE
Mailing Address - Street 2:STE. 201
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2911
Mailing Address - Country:US
Mailing Address - Phone:219-934-2461
Mailing Address - Fax:219-934-2478
Practice Address - Street 1:7905 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1215
Practice Address - Country:US
Practice Address - Phone:219-836-7214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001650A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100086890AMedicaid
IN410039709Medicare PIN
IN160450GMedicare PIN
INT92322Medicare UPIN
IN100086890AMedicaid
INM400047762Medicare PIN