Provider Demographics
NPI:1821206020
Name:BRADLEY UPSHAW OD INC
Entity Type:Organization
Organization Name:BRADLEY UPSHAW OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:UPSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:510-799-4258
Mailing Address - Street 1:671 PARKER AVE
Mailing Address - Street 2:
Mailing Address - City:RODEO
Mailing Address - State:CA
Mailing Address - Zip Code:94572-1434
Mailing Address - Country:US
Mailing Address - Phone:510-799-4258
Mailing Address - Fax:510-799-6616
Practice Address - Street 1:671 PARKER AVE
Practice Address - Street 2:
Practice Address - City:RODEO
Practice Address - State:CA
Practice Address - Zip Code:94572-1434
Practice Address - Country:US
Practice Address - Phone:510-799-4258
Practice Address - Fax:510-799-6616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-19
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11228152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11228TOtherOPTOMETRIC LICENSE
CASD0112280Medicare PIN
CAU76225Medicare UPIN