Provider Demographics
NPI:1811961097
Name:GADDIE, BRUCE JAY (OD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:JAY
Last Name:GADDIE
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 1:7635 SHELBYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5409
Mailing Address - Country:US
Mailing Address - Phone:502-423-8500
Mailing Address - Fax:502-339-0571
Practice Address - Street 1:7635 SHELBYVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5409
Practice Address - Country:US
Practice Address - Phone:502-423-8500
Practice Address - Fax:502-339-0571
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0746DT152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77007466Medicaid
KY000000068679OtherANTHEM
KY4379776OtherAETNA
KY9010601Medicare PIN
KY000000068679OtherANTHEM
0191960001Medicare NSC
KY77007466Medicaid