Provider Demographics
NPI:1386836518
Name:GRANT, BRADLEY STEWART (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:STEWART
Last Name:GRANT
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 1:1008 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-1784
Mailing Address - Country:US
Mailing Address - Phone:309-829-5311
Mailing Address - Fax:309-827-8027
Practice Address - Street 1:1008 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-1784
Practice Address - Country:US
Practice Address - Phone:309-829-5311
Practice Address - Fax:309-827-8027
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-12
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2737152W00000X
IL046010631152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist