MEDICARE: DR. SAM B BRADLEY 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	2229	AR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	0317710007	OTHER	AR	MEDICARE NSC-GREENWOOD CLINIC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	48940	OTHER	AR	BCBS

General Provider Information

NPI Number	:	1669445102
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAM B BRADLEY O.D.

Provider Business Mailing Address
First Line	:	500 N 6TH ST
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72901-2006
Country	:	US
Telephone Number	:	479-782-7272
Fax Number	:	479-782-7476

Provider Business Practice Location Address
First Line	:	500 N 6TH ST
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72901-2006
Country	:	US
Telephone Number	:	479-782-7272
Fax Number	:	479-782-7476

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

Provider Enumeration Date	:	02/07/2006
Last Update Date	:	03/14/2018

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