MEDICARE: DR. BRADLEY JAY LOUIS 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	1764	CO

General Provider Information

NPI Number	:	1356327852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY JAY LOUIS OD

Provider Business Mailing Address
First Line	:	32 LEISURE LN
Second Line	:
City	:	WOODLAND PARK
State	:	CO
Zip	:	80863-8702
Country	:	US
Telephone Number	:	719-231-8182
Fax Number	:

Provider Business Practice Location Address
First Line	:	750 CITADEL DR E
Second Line	:	#2300
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-5327
Country	:	US
Telephone Number	:	719-598-1392
Fax Number	:	719-591-0220

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

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	07/08/2007

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