Provider Demographics
NPI:1023245776
Name:BOHMAN, BRADLEY PETER (LO)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:PETER
Last Name:BOHMAN
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 OAK ST
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-1741
Mailing Address - Country:US
Mailing Address - Phone:401-596-9482
Mailing Address - Fax:
Practice Address - Street 1:VISION CENTER
Practice Address - Street 2:155 WATERFORD PKWY NORTH
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385
Practice Address - Country:US
Practice Address - Phone:860-437-3748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-19
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT632156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT581910859OtherTAX ID