Provider Demographics
NPI:1598704371
Name:HINES, BRADLEY N (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:N
Last Name:HINES
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 1:3445 POPLAR AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-4667
Mailing Address - Country:US
Mailing Address - Phone:901-458-2020
Mailing Address - Fax:901-458-2099
Practice Address - Street 1:3445 POPLAR AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-4667
Practice Address - Country:US
Practice Address - Phone:901-458-2020
Practice Address - Fax:901-458-2099
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2425152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3046240Medicare ID - Type Unspecified
TNU98777Medicare UPIN