Provider Demographics
NPI:1669534095
Name:BRALICH, JEFFREY A (LDO)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:A
Last Name:BRALICH
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 PARKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-2228
Mailing Address - Country:US
Mailing Address - Phone:724-342-5850
Mailing Address - Fax:
Practice Address - Street 1:116 FEDERAL PLZ W
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44503-1302
Practice Address - Country:US
Practice Address - Phone:330-743-5714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSC6087156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0906336Medicaid