Provider Demographics
NPI:1184613739
Name:WADLEY, BRUCE B (OD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:B
Last Name:WADLEY
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 1:1101 WATERS EDGE DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-1474
Mailing Address - Country:US
Mailing Address - Phone:817-579-7933
Mailing Address - Fax:817-579-8656
Practice Address - Street 1:1101 WATERS EDGE DR
Practice Address - Street 2:SUITE 104
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-1474
Practice Address - Country:US
Practice Address - Phone:817-579-7933
Practice Address - Fax:817-579-8656
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5503TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0190761Medicaid
TX0190761Medicaid
TX00009EMedicare ID - Type Unspecified
TX4776520001Medicare NSC