Healthcare Provider Details

I. General information

NPI: 1609624113
Provider Name (Legal Business Name): JAMES GIBSON BRADT OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2024
Last Update Date: 02/11/2026
Certification Date: 02/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SOUTHGATE STE 5
PENDLETON OR
97801-3974
US

IV. Provider business mailing address

1100 SOUTHGATE STE 5
PENDLETON OR
97801-3971
US

V. Phone/Fax

Practice location:
  • Phone: 541-310-1728
  • Fax:
Mailing address:
  • Phone: 541-203-3159
  • Fax: 541-203-3150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberATI4736
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: