Provider Demographics
NPI:1396776340
Name:PELTZER, BRADLEY ALAN (OD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:ALAN
Last Name:PELTZER
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 1:5952 W 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6814
Mailing Address - Country:US
Mailing Address - Phone:305-556-6946
Mailing Address - Fax:305-825-0845
Practice Address - Street 1:5952 W 16TH AVE
Practice Address - Street 2:ADVANCED EYE CARE OF HIALEAH, PA
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-6814
Practice Address - Country:US
Practice Address - Phone:305-556-6946
Practice Address - Fax:305-825-0845
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2646152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078929100Medicaid
FL20384BMedicare ID - Type Unspecified
FL20384BMedicare PIN
FL078929100Medicaid