Provider Demographics
NPI:1598102600
Name:ELLINGSON, BRADLEY (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:ELLINGSON
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 1:800 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHARLES CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50616-2218
Mailing Address - Country:US
Mailing Address - Phone:641-228-1732
Mailing Address - Fax:
Practice Address - Street 1:800 CLARK ST
Practice Address - Street 2:
Practice Address - City:CHARLES CITY
Practice Address - State:IA
Practice Address - Zip Code:50616-2218
Practice Address - Country:US
Practice Address - Phone:641-228-1732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2015-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002585152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist