Provider Demographics
NPI:1649215476
Name:BACKHAUS, BRADLEY L (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:L
Last Name:BACKHAUS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2404 1ST ST S
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-6300
Mailing Address - Country:US
Mailing Address - Phone:320-235-1235
Mailing Address - Fax:320-235-9241
Practice Address - Street 1:2404 1ST ST S
Practice Address - Street 2:SUITE 1
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-6300
Practice Address - Country:US
Practice Address - Phone:320-235-1235
Practice Address - Fax:320-235-9241
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN2069152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN398523700Medicaid
MN398523700Medicaid
MN410039108Medicare PIN
MNT65265Medicare UPIN