Basic Information
| Provider Information | |||||||||
| NPI: | 1407159890 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BYWATER | ||||||||
| FirstName: | BRADLEY | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 N MCKEMY AVE | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852262654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809611865 | ||||||||
| FaxNumber: | 4809614605 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 W COMBS RD STE 108 | ||||||||
| Address2: | |||||||||
| City: | SAN TAN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851409107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022394286 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2010 | ||||||||
| LastUpdateDate: | 02/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 956 | NV | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 1783 | AZ | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.