Provider Demographics
NPI:1699700807
Name:WIMMER, BRADLEY R (OD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:R
Last Name:WIMMER
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 1:411 E CENTENNIAL DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-6505
Mailing Address - Country:US
Mailing Address - Phone:620-232-1005
Mailing Address - Fax:620-231-5821
Practice Address - Street 1:411 E CENTENNIAL DR
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-6505
Practice Address - Country:US
Practice Address - Phone:620-232-1005
Practice Address - Fax:620-231-5821
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1270-02152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100219350BMedicaid
KSU34280Medicare UPIN
KS650858Medicare Oscar/Certification