Healthcare Provider Details

I. General information

NPI: 1407159890
Provider Name (Legal Business Name): BRADLEY BYWATER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2010
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1517 S SIGNAL BUTTE RD
MESA AZ
85209-1630
US

IV. Provider business mailing address

607 W DESERT SEASONS DR
SAN TAN VALLEY AZ
85143-3431
US

V. Phone/Fax

Practice location:
  • Phone: 602-308-2102
  • Fax:
Mailing address:
  • Phone: 971-678-7507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-001783
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: