Provider Demographics
NPI:1235544750
Name:AUSTIN, BRADLEY (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:AUSTIN
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 1:3056 SATILLA LOOP
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-2739
Mailing Address - Country:US
Mailing Address - Phone:954-696-3288
Mailing Address - Fax:
Practice Address - Street 1:8150 CITRUS PARK TOWN CENTER MALL STE 1100
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-3181
Practice Address - Country:US
Practice Address - Phone:813-920-6718
Practice Address - Fax:813-926-6619
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2021-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL4928152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014824000Medicaid