Provider Demographics
NPI:1992310312
Name:BROMLEY, JACOB RICHARD (OD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RICHARD
Last Name:BROMLEY
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 1:17439 N 57TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-3819
Mailing Address - Country:US
Mailing Address - Phone:925-708-5301
Mailing Address - Fax:
Practice Address - Street 1:725 E MAIN ST, APT #1C
Practice Address - Street 2:
Practice Address - City:SOMERTON
Practice Address - State:AZ
Practice Address - Zip Code:85350
Practice Address - Country:US
Practice Address - Phone:928-627-4525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ002462152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist