Provider Demographics
NPI:1083611198
Name:CLAIR, BRADLEY TRENT (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:TRENT
Last Name:CLAIR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3536 MENDOCINO AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3634
Mailing Address - Country:US
Mailing Address - Phone:707-575-6049
Mailing Address - Fax:707-263-8137
Practice Address - Street 1:5196 HILL RD E
Practice Address - Street 2:STE 202
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-6360
Practice Address - Country:US
Practice Address - Phone:707-263-1777
Practice Address - Fax:707-263-8137
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA45681207RC0000X, 207RI0011X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A456810Medicaid
CA00A456810OtherBLUE SHIELD OF CALIFORNIA
CA060020642OtherRAILROAD MEDICARE
CAF59210Medicare UPIN
CADW836ZMedicare PIN
CA00A456811Medicare PIN
CA00A456812Medicare PIN