Provider Demographics
NPI:1780654046
Name:KNOX, BRADLEY JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JOSEPH
Last Name:KNOX
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 1:1030 ALABAR AVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-3200
Mailing Address - Country:US
Mailing Address - Phone:319-233-5096
Mailing Address - Fax:319-287-9022
Practice Address - Street 1:1030 ALABAR AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-3200
Practice Address - Country:US
Practice Address - Phone:319-233-5096
Practice Address - Fax:319-287-9022
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02141152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0269928Medicaid
IA33057OtherBLUE CROSS/BLUE SHEILD
IA33057OtherBLUE CROSS/BLUE SHEILD
IA05140Medicare ID - Type Unspecified
IAU76838Medicare UPIN
P00096814Medicare PIN
IAIB1603002Medicare PIN
IAI11102Medicare PIN