MEDICARE: DR. ERIC BRADFORD VANAUSDAL OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT-002261	AZ

General Provider Information

NPI Number	:	1255826681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC BRADFORD VANAUSDAL OD

Provider Business Mailing Address
First Line	:	15215 S 48TH ST STE 180
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85044-9140
Country	:	US
Telephone Number	:	480-706-3937
Fax Number	:

Provider Business Practice Location Address
First Line	:	15215 S 48TH ST STE 180
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85044-9140
Country	:	US
Telephone Number	:	480-706-3937
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2018
Last Update Date	:	06/27/2018

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