Provider Demographics
NPI:1457321135
Name:CUDAHY, BRUCE GERALD (OD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:GERALD
Last Name:CUDAHY
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 1:9801 204TH AVE E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-6559
Mailing Address - Country:US
Mailing Address - Phone:253-750-8135
Mailing Address - Fax:253-750-8136
Practice Address - Street 1:9801 204TH AVE E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-6559
Practice Address - Country:US
Practice Address - Phone:253-750-8135
Practice Address - Fax:253-750-8136
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1641152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2001360Medicaid
WAT02831Medicare ID - Type Unspecified