Provider Demographics
NPI:1679575187
Name:MIDDAUGH, BRADLEY DAVID (OD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DAVID
Last Name:MIDDAUGH
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 1:1360 E VENICE AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-9066
Mailing Address - Country:US
Mailing Address - Phone:941-480-2135
Mailing Address - Fax:
Practice Address - Street 1:1537 BRANTLEY RD
Practice Address - Street 2:UNIT A2
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3923
Practice Address - Country:US
Practice Address - Phone:239-481-7799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC0002377152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19695WOtherMEDICARE PTAN
FL078638100Medicaid
FL19695WOtherMEDICARE PTAN