Healthcare Provider Details

I. General information

NPI: 1205065588
Provider Name (Legal Business Name): ANDREA K BRADEN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2009
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47670 VAN DYKE AVE
SHELBY TOWNSHIP MI
48317-3302
US

IV. Provider business mailing address

30150 TELEGRAPH RD STE 271
BINGHAM FARMS MI
48025-4521
US

V. Phone/Fax

Practice location:
  • Phone: 586-323-2020
  • Fax: 586-323-4145
Mailing address:
  • Phone: 248-395-5166
  • Fax: 586-323-4145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5847
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1773DT
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT2761
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004563
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: