MEDICARE: ROCKATONIA BRADLEY

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	1851DT	KY
2	152W00000X	Optometrist	5319	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000725449	OTHER	KY	ANTHEM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427346295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROCKATONIA BRADLEY

Provider Business Mailing Address
First Line	:	700 BARRINGTON DR
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-0916
Country	:	US
Telephone Number	:	270-339-6179
Fax Number	:

Provider Business Practice Location Address
First Line	:	1523 SADLER RD
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-4467
Country	:	US
Telephone Number	:	270-277-2779
Fax Number	:	270-277-2779

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

Provider Enumeration Date	:	07/14/2011
Last Update Date	:	07/21/2022

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Directions to “ ROCKATONIA BRADLEY ” Practice Location

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