Provider Demographics
NPI:1528048469
Name:DRAKE, BRADLEY (OD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:DRAKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:697 HIGHWAY 31 NW
Mailing Address - Street 2:
Mailing Address - City:HARTSELLE
Mailing Address - State:AL
Mailing Address - Zip Code:35640-2849
Mailing Address - Country:US
Mailing Address - Phone:256-773-3997
Mailing Address - Fax:
Practice Address - Street 1:697 HIGHWAY 31 NW
Practice Address - Street 2:
Practice Address - City:HARTSELLE
Practice Address - State:AL
Practice Address - Zip Code:35640-4408
Practice Address - Country:US
Practice Address - Phone:256-773-3997
Practice Address - Fax:256-773-8993
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALSA49TA629152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009937485Medicaid
AL009937485Medicaid
AL051554122Medicare PIN