Provider Demographics
NPI:1346224920
Name:BRADFORD, MICHAEL B (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:BRADFORD
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 1:2752 ZELDA RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2694
Mailing Address - Country:US
Mailing Address - Phone:334-271-3804
Mailing Address - Fax:334-270-3375
Practice Address - Street 1:2752 ZELDA RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2694
Practice Address - Country:US
Practice Address - Phone:334-271-3804
Practice Address - Fax:334-270-3375
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5565TA138152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T69139Medicare UPIN
AL38736Medicare ID - Type Unspecified