Provider Demographics
NPI:1881141562
Name:POWERS, BRADLEY (OD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:POWERS
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 1:470 TOWN CENTER PL STE 5
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7957
Mailing Address - Country:US
Mailing Address - Phone:803-865-3901
Mailing Address - Fax:
Practice Address - Street 1:470 TOWN CENTER PL STE 5
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-7957
Practice Address - Country:US
Practice Address - Phone:803-865-3901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-09
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0003269152W00000X
WAOD 60701770152W00000X
SCSC 1967152W00000X
IDODP - 100386152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist