Provider Demographics
NPI:1053316158
Name:EBRIGHT, BRADFORD LEWIS (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:LEWIS
Last Name:EBRIGHT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9524 BELAIR RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-1508
Mailing Address - Country:US
Mailing Address - Phone:410-529-9311
Mailing Address - Fax:
Practice Address - Street 1:9524 BELAIR RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-1508
Practice Address - Country:US
Practice Address - Phone:410-529-9311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2007-09-26
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
MDD0045568207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF88952Medicare UPIN
KQ67CHMedicare ID - Type Unspecified