Provider Demographics
NPI:1922000975
Name:SMITH, BRADLEY JAY (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JAY
Last Name:SMITH
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 1:6002 E HARTFORD AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-5902
Mailing Address - Country:US
Mailing Address - Phone:602-265-5172
Mailing Address - Fax:602-265-5171
Practice Address - Street 1:300 W CLARENDON AVE
Practice Address - Street 2:STE 150
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3405
Practice Address - Country:US
Practice Address - Phone:602-265-0343
Practice Address - Fax:602-265-2809
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ542152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ66764Medicare ID - Type Unspecified
AZU16782Medicare UPIN