Provider Demographics
NPI:1073516381
Name:FOLKESTAD, BRADLEY JOHN (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JOHN
Last Name:FOLKESTAD
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 1:18699 N 67TH AVE
Mailing Address - Street 2:STE 320
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7143
Mailing Address - Country:US
Mailing Address - Phone:623-561-7250
Mailing Address - Fax:623-561-0098
Practice Address - Street 1:18699 N 67TH AVE
Practice Address - Street 2:STE 320
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7143
Practice Address - Country:US
Practice Address - Phone:623-561-7250
Practice Address - Fax:623-561-0098
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19824207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ106246Medicaid
AZZMD19824Medicare ID - Type Unspecified
AZ106246Medicaid