Provider Demographics
NPI:1992731335
Name:UPSHAW, BRADLEY GEORGE (OD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:GEORGE
Last Name:UPSHAW
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 1:671 PARKER AVE
Mailing Address - Street 2:
Mailing Address - City:RODEO
Mailing Address - State:CA
Mailing Address - Zip Code:94572-1434
Mailing Address - Country:US
Mailing Address - Phone:510-799-4258
Mailing Address - Fax:510-799-6616
Practice Address - Street 1:671 PARKER AVE
Practice Address - Street 2:
Practice Address - City:RODEO
Practice Address - State:CA
Practice Address - Zip Code:94572-1434
Practice Address - Country:US
Practice Address - Phone:510-799-4258
Practice Address - Fax:510-799-6616
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11228T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0112280Medicaid
CA11228TOtherSTATE OPTOMETRIC LICENSE
CA11228TOtherSTATE OPTOMETRIC LICENSE
CASD0112280Medicaid
CAMU0638772OtherDEA NUMBER