MEDICARE: BRADLEY UPSHAW OD INC

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	11228	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11228T	OTHER	CA	OPTOMETRIC LICENSE

General Provider Information

NPI Number	:	1821206020
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRADLEY UPSHAW OD INC

Provider Business Mailing Address
First Line	:	671 PARKER AVE
Second Line	:
City	:	RODEO
State	:	CA
Zip	:	94572-1434
Country	:	US
Telephone Number	:	510-799-4258
Fax Number	:	510-799-6616

Provider Business Practice Location Address
First Line	:	671 PARKER AVE
Second Line	:
City	:	RODEO
State	:	CA
Zip	:	94572-1434
Country	:	US
Telephone Number	:	510-799-4258
Fax Number	:	510-799-6616

Authorized Official
Title or Position	:	OWNER OPTOMETRIST
Name	:	BRADLEY GEORGE UPSHAW
Credential	:	OD
Telephone Number	:	510-799-4258

Provider Enumeration Date	:	05/19/2007
Last Update Date	:	03/29/2012

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