Provider Demographics
NPI:1134133960
Name:FREESTONE, BRADLEY DALLAS (OD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DALLAS
Last Name:FREESTONE
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3223 N WINDSONG DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-1222
Mailing Address - Country:US
Mailing Address - Phone:928-775-6121
Mailing Address - Fax:928-775-6301
Practice Address - Street 1:3223 N WINDSONG DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-1222
Practice Address - Country:US
Practice Address - Phone:480-892-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6255330-8908152W00000X
UT6255330-9934152WL0500X, 152WV0400X
AZOPT002834152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD7028Medicaid
AZ324761Medicaid