Provider Demographics
NPI:1457704256
Name:BRADSHAW, TIMOTHY LEWIS (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:LEWIS
Last Name:BRADSHAW
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:PO BOX 45923
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-5923
Mailing Address - Country:US
Mailing Address - Phone:877-969-0392
Mailing Address - Fax:
Practice Address - Street 1:927 MAPLE GROVE DR STE 209
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-6936
Practice Address - Country:US
Practice Address - Phone:540-208-5827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-15
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002957152W00000X
AZ2203152W00000X
VA0618003248152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist