Provider Demographics
NPI:1275621161
Name:BRADLEY, JASON L (OD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:L
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 1:207 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-3915
Mailing Address - Country:US
Mailing Address - Phone:701-852-5626
Mailing Address - Fax:
Practice Address - Street 1:207 MAIN ST S
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3915
Practice Address - Country:US
Practice Address - Phone:701-852-5626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND544152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND21332OtherBLUE CROSS BLUE SHIELD
ND60504Medicaid
ND870544OtherVISION SERVICES, INC.
ND60504Medicaid
ND21332OtherBLUE CROSS BLUE SHIELD