Provider Demographics
NPI:1992725436
Name:CALLIES, BRADLEY LYN (OD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:LYN
Last Name:CALLIES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:BRAD
Other - Middle Name:
Other - Last Name:CALLIES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:17 7TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:MN
Mailing Address - Zip Code:55920-1470
Mailing Address - Country:US
Mailing Address - Phone:605-352-1904
Mailing Address - Fax:
Practice Address - Street 1:127 W VINE ST
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-2320
Practice Address - Country:US
Practice Address - Phone:507-451-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD589152W00000X
MN3308152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9201292Medicaid
SD101006Medicare PIN
SD9201292Medicaid