Healthcare Provider Details

I. General information

NPI: 1457321135
Provider Name (Legal Business Name): BRUCE GERALD CUDAHY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9801 204TH AVE E
BONNEY LAKE WA
98391-6559
US

IV. Provider business mailing address

9801 204TH AVE E
BONNEY LAKE WA
98391-6559
US

V. Phone/Fax

Practice location:
  • Phone: 253-750-8135
  • Fax: 253-750-8136
Mailing address:
  • Phone: 253-750-8135
  • Fax: 253-750-8136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1641
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: