Provider Demographics
NPI:1326099862
Name:CROSS, BRADLEY T (OD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:T
Last Name:CROSS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:44332 STERLING HWY STE 52
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-8065
Mailing Address - Country:US
Mailing Address - Phone:907-260-9199
Mailing Address - Fax:907-260-9189
Practice Address - Street 1:44332 STERLING HWY
Practice Address - Street 2:STE 52
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-8065
Practice Address - Country:US
Practice Address - Phone:907-260-9199
Practice Address - Fax:907-260-9189
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK326152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000764013BMedicaid
GA41ZCCLC-01Medicare ID - Type Unspecified
GA000764013BMedicaid