Provider Demographics
NPI:1336182369
Name:COFFEY, BRADLEY (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:COFFEY
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 1:511 SW 10TH AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2732
Mailing Address - Country:US
Mailing Address - Phone:503-352-2500
Mailing Address - Fax:503-352-2523
Practice Address - Street 1:511 SW 10TH AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2732
Practice Address - Country:US
Practice Address - Phone:503-352-2500
Practice Address - Fax:503-352-2523
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1527T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist