Healthcare Provider Details

I. General information

NPI: 1134133960
Provider Name (Legal Business Name): BRADLEY DALLAS FREESTONE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 N WINDSONG DR
PRESCOTT VALLEY AZ
86314-1222
US

IV. Provider business mailing address

3223 N WINDSONG DR
PRESCOTT VALLEY AZ
86314-1222
US

V. Phone/Fax

Practice location:
  • Phone: 480-892-8400
  • Fax:
Mailing address:
  • Phone: 928-775-6121
  • Fax: 928-775-6301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6255330-8908
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number6255330-9934
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number6255330-9934
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT002834
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: