Provider Demographics
NPI:1104072024
Name:BRADLEY J CLODFELTER OD, P.C.
Entity type:Organization
Organization Name:BRADLEY J CLODFELTER OD, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLODFELTER, O.D., P.C.
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:773-238-2142
Mailing Address - Street 1:3225 W 111TH ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-2745
Mailing Address - Country:US
Mailing Address - Phone:773-238-2142
Mailing Address - Fax:773-238-9461
Practice Address - Street 1:3225 W 111TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-2745
Practice Address - Country:US
Practice Address - Phone:773-238-2142
Practice Address - Fax:773-238-9461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007766152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDN7029OtherRAILROAD MEDICARE
IL216875Medicare PIN
IL736130Medicare PIN
ILDN7029OtherRAILROAD MEDICARE