Healthcare Provider Details

I. General information

NPI: 1457704256
Provider Name (Legal Business Name): TIMOTHY LEWIS BRADSHAW O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2016
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 EASTLAKE PKWY
CHULA VISTA CA
91915-4116
US

IV. Provider business mailing address

1360 EASTLAKE PKWY
CHULA VISTA CA
91915-4116
US

V. Phone/Fax

Practice location:
  • Phone: 619-500-5038
  • Fax:
Mailing address:
  • Phone: 619-500-5038
  • Fax: 619-361-7152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT002957
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number36196
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618003245
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2203
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: