Healthcare Provider Details

I. General information

NPI: 1104816545
Provider Name (Legal Business Name): BRADLEY MILES KARDATZKE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 N MACARTHUR BLVD
IRVING TX
75061-7355
US

IV. Provider business mailing address

PO BOX 153328
IRVING TX
75015-3328
US

V. Phone/Fax

Practice location:
  • Phone: 972-254-0033
  • Fax: 972-254-0055
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4929TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: