Provider Demographics
NPI:1396863387
Name:EWALD, BRAD HAROLD (OD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:HAROLD
Last Name:EWALD
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 1:2900 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868
Mailing Address - Country:US
Mailing Address - Phone:715-234-1511
Mailing Address - Fax:715-434-1513
Practice Address - Street 1:2900 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868
Practice Address - Country:US
Practice Address - Phone:715-234-1511
Practice Address - Fax:715-434-1513
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1347-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist