Healthcare Provider Details

I. General information

NPI: 1780662734
Provider Name (Legal Business Name): BRADLEY D PACKER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7763 E FLORENTINE RD
PRESCOTT VALLEY AZ
86314-2289
US

IV. Provider business mailing address

1203 N STILLNESS DR
PRESCOTT VALLEY AZ
86314-1491
US

V. Phone/Fax

Practice location:
  • Phone: 928-775-9393
  • Fax:
Mailing address:
  • Phone: 928-379-1107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3845
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberAZ-OPT001621
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: