Provider Demographics
NPI:1356327852
Name:LOUIS, BRADLEY JAY (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JAY
Last Name:LOUIS
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 1:32 LEISURE LN
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80863-8702
Mailing Address - Country:US
Mailing Address - Phone:719-231-8182
Mailing Address - Fax:
Practice Address - Street 1:750 CITADEL DR E
Practice Address - Street 2:#2300
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5327
Practice Address - Country:US
Practice Address - Phone:719-598-1392
Practice Address - Fax:719-591-0220
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1764152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U12920Medicare UPIN
CO801125Medicare ID - Type Unspecified