Provider Demographics
NPI:1740693431
Name:ENGELBARTS, BRAD (OD)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:ENGELBARTS
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:881 USS JAMES MADISON RD BLDG 1028
Mailing Address - Street 2:
Mailing Address - City:KINGS BAY
Mailing Address - State:GA
Mailing Address - Zip Code:31547-2531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2080 CHILD ST DEPT 5000
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-6122
Practice Address - Country:US
Practice Address - Phone:125-734-2279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1818152W00000X
MO2017043011152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist