Provider Demographics
NPI:1821077124
Name:FARLOW, BRADLEY A (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:A
Last Name:FARLOW
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:PO BOX 647
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-0647
Mailing Address - Country:US
Mailing Address - Phone:260-563-2020
Mailing Address - Fax:260-563-2873
Practice Address - Street 1:144 W HILL ST
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-3048
Practice Address - Country:US
Practice Address - Phone:260-563-2020
Practice Address - Fax:260-563-2873
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002054A152WC0802X, 152W00000X, 152WX0102X, 152WP0200X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100253500BMedicaid
IN000000088323OtherANTHEM BLUE CROSS & SHIEL
IN134927OtherEYEMED VISION CARE
IN134927OtherEYEMED VISION CARE
IN100253500BMedicaid
IN861260AMedicare PIN