MEDICARE: DR. BRADLEY DAVID MIDDAUGH 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	OPC0002377	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	19695W	OTHER	FL	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679575187
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY DAVID MIDDAUGH O.D.

Provider Business Mailing Address
First Line	:	1360 E VENICE AVE
Second Line	:
City	:	VENICE
State	:	FL
Zip	:	34285-9066
Country	:	US
Telephone Number	:	941-480-2135
Fax Number	:

Provider Business Practice Location Address
First Line	:	1537 BRANTLEY RD
Second Line	:	UNIT A2
City	:	FORT MYERS
State	:	FL
Zip	:	33907-3923
Country	:	US
Telephone Number	:	239-481-7799
Fax Number	:

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

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	02/24/2022

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