Provider Demographics
NPI:1508850298
Name:LUTTRELL, BRADLEY JOHNSON (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JOHNSON
Last Name:LUTTRELL
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 1:90 VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-6478
Mailing Address - Country:US
Mailing Address - Phone:865-482-8890
Mailing Address - Fax:865-482-7400
Practice Address - Street 1:90 VERMONT AVE
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6478
Practice Address - Country:US
Practice Address - Phone:865-482-8890
Practice Address - Fax:865-482-7400
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000038353207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3891609Medicaid
3891609Medicare ID - Type Unspecified
TN3891609Medicaid