Provider Demographics
NPI:1780662734
Name:PACKER, BRADLEY D (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:D
Last Name:PACKER
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 1:1203 N STILLNESS DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-1491
Mailing Address - Country:US
Mailing Address - Phone:928-379-1107
Mailing Address - Fax:
Practice Address - Street 1:7763 E FLORENTINE RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2289
Practice Address - Country:US
Practice Address - Phone:928-775-9393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3845152W00000X
AZAZ-OPT001621152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist