Provider Demographics
NPI:1326304247
Name:HALL, BRADLEY INGALLS (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:INGALLS
Last Name:HALL
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 1:1900 SANTA ROSA AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-7621
Mailing Address - Country:US
Mailing Address - Phone:707-570-2418
Mailing Address - Fax:707-566-6430
Practice Address - Street 1:1900 SANTA ROSA AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-7621
Practice Address - Country:US
Practice Address - Phone:707-570-2418
Practice Address - Fax:707-566-6430
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10644T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist