Provider Demographics
NPI:1851619506
Name:BRADLEY EYE ASSOCIATES, INC
Entity Type:Organization
Organization Name:BRADLEY EYE ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:G
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:706-276-4455
Mailing Address - Street 1:772 MADDOX DR
Mailing Address - Street 2:SUITE 132
Mailing Address - City:EAST ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-8194
Mailing Address - Country:US
Mailing Address - Phone:706-276-4455
Mailing Address - Fax:706-276-4458
Practice Address - Street 1:772 MADDOX DR
Practice Address - Street 2:SUITE 132
Practice Address - City:EAST ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-8194
Practice Address - Country:US
Practice Address - Phone:706-276-4455
Practice Address - Fax:706-276-4458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-05
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT 001314152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000514599AMedicaid
GA000514599AMedicaid
GAU35671Medicare UPIN