Provider Demographics
NPI:1598017840
Name:POLAN, BRADLEY (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:POLAN
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8202 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-7023
Mailing Address - Country:US
Mailing Address - Phone:718-478-3539
Mailing Address - Fax:718-205-0963
Practice Address - Street 1:8202 37TH AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7023
Practice Address - Country:US
Practice Address - Phone:718-478-3539
Practice Address - Fax:718-205-0963
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006299-2156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic