Provider Demographics
NPI:1710026653
Name:KIRCHNER, BRADLEY S (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:S
Last Name:KIRCHNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:28 BLANDING BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-2202
Practice Address - Country:US
Practice Address - Phone:904-264-5483
Practice Address - Fax:904-213-0515
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4284152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9233130Medicaid
MK1041982OtherDEA
MK1041982OtherDEA
VA410000542Medicare ID - Type Unspecified