Healthcare Provider Details

I. General information

NPI: 1780654046
Provider Name (Legal Business Name): BRADLEY JOSEPH KNOX O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 04/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 ALABAR AVE
WATERLOO IA
50701-3200
US

IV. Provider business mailing address

1030 ALABAR AVE
WATERLOO IA
50701-3200
US

V. Phone/Fax

Practice location:
  • Phone: 319-233-5096
  • Fax: 319-287-9022
Mailing address:
  • Phone: 319-233-5096
  • Fax: 319-287-9022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number02141
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: