Provider Demographics
NPI:1790786093
Name:CAMP, BRADLEY S (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:S
Last Name:CAMP
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 1:103 FRONT ST
Mailing Address - Street 2:PO BOX 333
Mailing Address - City:NORTH MANCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46962-1529
Mailing Address - Country:US
Mailing Address - Phone:260-982-8798
Mailing Address - Fax:260-982-1822
Practice Address - Street 1:103 N FRONT ST
Practice Address - Street 2:
Practice Address - City:NORTH MANCHESTER
Practice Address - State:IN
Practice Address - Zip Code:46962-1529
Practice Address - Country:US
Practice Address - Phone:260-982-8798
Practice Address - Fax:260-982-1822
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001838152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ1838OtherEYEMED VISION CARE
IN100105320AMedicaid
000000288123OtherANTHEM
0431150001Medicare NSC
204420Medicare PIN
410000175Medicare PIN
ININ1838OtherEYEMED VISION CARE
IN204420Medicare ID - Type Unspecified
204420Medicare PIN