Provider Demographics
NPI:1841473295
Name:FELLOWS, BRADLEY V (OD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:V
Last Name:FELLOWS
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 1:9035 S 1300 E
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3132
Mailing Address - Country:US
Mailing Address - Phone:801-566-4119
Mailing Address - Fax:801-568-3844
Practice Address - Street 1:9035 S 1300 E
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3132
Practice Address - Country:US
Practice Address - Phone:801-566-4119
Practice Address - Fax:801-568-3844
Is Sole Proprietor?:No
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT113508-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist