Provider Demographics
NPI:1669445102
Name:BRADLEY, SAM B (OD)
Entity type:Individual
Prefix:DR
First Name:SAM
Middle Name:B
Last Name:BRADLEY
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 1:500 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-2006
Mailing Address - Country:US
Mailing Address - Phone:479-782-7272
Mailing Address - Fax:479-782-7476
Practice Address - Street 1:500 N 6TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-2006
Practice Address - Country:US
Practice Address - Phone:479-782-7272
Practice Address - Fax:479-782-7476
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2229152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105771722Medicaid
AR0317710007OtherMEDICARE NSC-GREENWOOD CLINIC
OK100760710AMedicaid
AR48940OtherBCBS
AR48940Medicare ID - Type Unspecified
ART20253Medicare UPIN
AR0317710007OtherMEDICARE NSC-GREENWOOD CLINIC