Provider Demographics
NPI:1225101165
Name:BRADLEY, GARNER BURT (OD)
Entity Type:Individual
Prefix:DR
First Name:GARNER
Middle Name:BURT
Last Name:BRADLEY
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 1:4214 41ST ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79413-2910
Mailing Address - Country:US
Mailing Address - Phone:806-792-3946
Mailing Address - Fax:806-798-9944
Practice Address - Street 1:5201 68TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-1508
Practice Address - Country:US
Practice Address - Phone:806-798-9955
Practice Address - Fax:806-798-9944
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02590152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU14092Medicare UPIN