Provider Demographics
NPI:1013935006
Name:BANGSTAD, BRADLEY P (OD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:P
Last Name:BANGSTAD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:BRAD
Other - Middle Name:
Other - Last Name:BANGSTAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:4220 NW 16TH BLVD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-3508
Mailing Address - Country:US
Mailing Address - Phone:352-331-5440
Mailing Address - Fax:352-271-3353
Practice Address - Street 1:4220 NW 16TH BLVD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-3508
Practice Address - Country:US
Practice Address - Phone:352-331-5440
Practice Address - Fax:352-271-3353
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 1898152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621121600Medicaid
FL38049Medicare UPIN
FL20395Medicare ID - Type Unspecified