Provider Demographics
NPI:1790762821
Name:CHURCH, BRADLEY W (OD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:W
Last Name:CHURCH
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 1:15189 MONTANUS DR
Mailing Address - Street 2:
Mailing Address - City:CULPEPER
Mailing Address - State:VA
Mailing Address - Zip Code:22701-1679
Mailing Address - Country:US
Mailing Address - Phone:540-825-8220
Mailing Address - Fax:866-691-2912
Practice Address - Street 1:15189 MONTANUS DR
Practice Address - Street 2:
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701-1679
Practice Address - Country:US
Practice Address - Phone:540-825-8220
Practice Address - Fax:866-691-2912
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2011-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000722152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA410036701Medicaid
VA410036701Medicaid
VAC10892Medicare PIN