Provider Demographics
NPI:1790022978
Name:BRADLEY T CROSS OD PC
Entity Type:Organization
Organization Name:BRADLEY T CROSS OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:T
Authorized Official - Last Name:CROSS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:907-260-9199
Mailing Address - Street 1:35605 K BEACH RD
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-8770
Mailing Address - Country:US
Mailing Address - Phone:678-234-7869
Mailing Address - Fax:
Practice Address - Street 1:44332 STERLING HWY STE 52
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-8065
Practice Address - Country:US
Practice Address - Phone:907-260-9199
Practice Address - Fax:907-260-9189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK326152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
41ZCCLC01Medicare PIN
GAU47932Medicare UPIN