Provider Demographics
NPI:1841269040
Name:BRADLEY, MARK STEPHEN (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEPHEN
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 1:322 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAYERISE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684
Mailing Address - Country:US
Mailing Address - Phone:231-933-4788
Mailing Address - Fax:231-933-4845
Practice Address - Street 1:322 E FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAYERISE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-933-4788
Practice Address - Fax:231-933-4845
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003660152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMB0978075OtherDEA
MIOM79950Medicare ID - Type Unspecified
MIMB0978075OtherDEA