Provider Demographics
NPI:1235432600
Name:BRADSHAW OPTOMETRY CORP
Entity Type:Organization
Organization Name:BRADSHAW OPTOMETRY CORP
Other - Org Name:BRADSHAW OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:K
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:916-361-2020
Mailing Address - Street 1:3557 BRADSHAW RD #2E
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-3373
Mailing Address - Country:US
Mailing Address - Phone:916-361-2020
Mailing Address - Fax:916-361-0433
Practice Address - Street 1:3557 BRADSHAW RD STE 2E
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95827-3373
Practice Address - Country:US
Practice Address - Phone:916-361-2020
Practice Address - Fax:916-361-0433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-07
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10618T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6526430Medicare UPIN
CASD0106180Medicare PIN