Healthcare Provider Details

I. General information

NPI: 1255826681
Provider Name (Legal Business Name): ERIC BRADFORD VANAUSDAL OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21321 E OCOTILLO RD STE 105
QUEEN CREEK AZ
85142-5993
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 480-656-7739
  • Fax:
Mailing address:
  • Phone: 703-847-8899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-002261
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: