Provider Demographics
NPI:1245210483
Name:SMURR, BRADLEY JACKSON (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JACKSON
Last Name:SMURR
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 1:13940 7TH ST
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33525-4904
Mailing Address - Country:US
Mailing Address - Phone:352-521-3011
Mailing Address - Fax:352-521-7163
Practice Address - Street 1:13940 7TH ST
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-4904
Practice Address - Country:US
Practice Address - Phone:352-521-3011
Practice Address - Fax:352-521-7163
Is Sole Proprietor?:No
Enumeration Date:2006-01-21
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2393152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20246OtherBCBS
4609006OtherAETNA
FL20246OtherBCBS
P00134557Medicare ID - Type UnspecifiedMEDICARE RAILROAD