Provider Demographics
NPI:1962061523
Name:SULTAN, BRADLEY
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:SULTAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9315 MORNING WALK DR
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-1485
Mailing Address - Country:US
Mailing Address - Phone:443-639-5907
Mailing Address - Fax:
Practice Address - Street 1:9315 MORNING WALK DR
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-1485
Practice Address - Country:US
Practice Address - Phone:443-639-5907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-07
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
46-1389078OtherEYEWEAR