Provider Demographics
NPI:1366446338
Name:BRADLEY, BONNIE G (OD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:G
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:772 MADDOX DR
Mailing Address - Street 2:SUITE 132
Mailing Address - City:EAST ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-8194
Mailing Address - Country:US
Mailing Address - Phone:706-276-4455
Mailing Address - Fax:706-276-4458
Practice Address - Street 1:772 MADDOX DR
Practice Address - Street 2:SUITE 132
Practice Address - City:EAST ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-8194
Practice Address - Country:US
Practice Address - Phone:706-276-4455
Practice Address - Fax:706-276-4458
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001314152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00514599AMedicaid
GA00514599AMedicaid
GAU35671Medicare UPIN