Provider Demographics
NPI:1073579322
Name:BRADLEY, STANLEY (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:BRADLEY
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 1:325 E LONGVIEW STREET
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4618
Mailing Address - Country:US
Mailing Address - Phone:479-463-7385
Mailing Address - Fax:
Practice Address - Street 1:325 E LONGVIEW STREET
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4618
Practice Address - Country:US
Practice Address - Phone:479-463-7385
Practice Address - Fax:479-444-7120
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-5957207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR103929001Medicaid
AR50584Medicare PIN
D04382Medicare UPIN