Provider Demographics
NPI:1003325499
Name:STILLEY, BRADLY JAMES (IDC)
Entity Type:Individual
Prefix:
First Name:BRADLY
Middle Name:JAMES
Last Name:STILLEY
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10156 ORLECK ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-2509
Mailing Address - Country:US
Mailing Address - Phone:360-941-9989
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:360-941-9989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty CorpsmanGroup - Single Specialty