Provider Demographics
NPI:1942448675
Name:MUNDY, BRADLEY P (OD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:P
Last Name:MUNDY
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 1:400 E FRONT ST
Mailing Address - Street 2:STE A
Mailing Address - City:BUCHANAN
Mailing Address - State:MI
Mailing Address - Zip Code:49107-1403
Mailing Address - Country:US
Mailing Address - Phone:269-695-3434
Mailing Address - Fax:269-695-2656
Practice Address - Street 1:400 E FRONT ST
Practice Address - Street 2:STE A
Practice Address - City:BUCHANAN
Practice Address - State:MI
Practice Address - Zip Code:49107-1403
Practice Address - Country:US
Practice Address - Phone:269-695-3434
Practice Address - Fax:269-695-2656
Is Sole Proprietor?:No
Enumeration Date:2009-02-03
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003559152W00000X
MI4901004630152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist