Provider Demographics
NPI:1235311523
Name:BRADLEY D FOURAKER MD LLC
Entity Type:Organization
Organization Name:BRADLEY D FOURAKER MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:FOURAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-287-2121
Mailing Address - Street 1:4905 W BAY WAY PL
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-4833
Mailing Address - Country:US
Mailing Address - Phone:813-287-2121
Mailing Address - Fax:
Practice Address - Street 1:4905 W BAY WAY PL
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-4833
Practice Address - Country:US
Practice Address - Phone:813-287-2121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME60284207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAI645Medicare PIN
FLC75163Medicare UPIN
FL14958Medicare PIN
FL14958TMedicare PIN