MEDICARE: DR. BRADLEY WAITE O.D.

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	764	NV

General Provider Information

NPI Number	:	1487095212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY WAITE O.D.

Provider Business Mailing Address
First Line	:	7335 S PECOS RD
Second Line	:	SUITE #101
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-3735
Country	:	US
Telephone Number	:	702-451-1522
Fax Number	:

Provider Business Practice Location Address
First Line	:	7335 S PECOS RD
Second Line	:	SUITE #101
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-3735
Country	:	US
Telephone Number	:	702-451-1522
Fax Number	:

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

Provider Enumeration Date	:	07/09/2013
Last Update Date	:	12/10/2014

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