Provider Demographics
NPI:1174774079
Name:MARTINSON, BRADLEY D (OD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:D
Last Name:MARTINSON
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:PO BOX 5040
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035
Mailing Address - Country:US
Mailing Address - Phone:618-466-8787
Mailing Address - Fax:618-466-4703
Practice Address - Street 1:3300 GODFREY RD
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035
Practice Address - Country:US
Practice Address - Phone:618-466-8787
Practice Address - Fax:618-466-4703
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010101152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00880071OtherRAILROAD MEDICARE
IL046010101Medicaid
ILP00880071OtherRAILROAD MEDICARE
IL046010101Medicaid