Provider Demographics
NPI:1467445866
Name:FOURAKER, BRADLEY D (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:D
Last Name:FOURAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 VONDERBURG DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5982
Mailing Address - Country:US
Mailing Address - Phone:813-681-1122
Mailing Address - Fax:813-684-4924
Practice Address - Street 1:403 VONDERBURG DR
Practice Address - Street 2:STE 101
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5982
Practice Address - Country:US
Practice Address - Phone:813-681-1122
Practice Address - Fax:813-684-4924
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME60284207WX0120X
FLME0060284207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4414165OtherAETNA
FL1674799OtherCIGNA
FL14958OtherBCBS FORIDA
FL2439747OtherAETNA
NY0498749OtherGHI
FL370277400Medicaid
FL370277400Medicaid
FL14958UMedicare PIN
FL4414165OtherAETNA
GA180039310Medicare PIN
FL14958TMedicare PIN
FL2439747OtherAETNA