Provider Demographics
NPI:1093931644
Name:ROBISON, BRADLEY D (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:D
Last Name:ROBISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2238 COUNTY ROAD 262
Mailing Address - Street 2:
Mailing Address - City:ADVANCE
Mailing Address - State:MO
Mailing Address - Zip Code:63730-9027
Mailing Address - Country:US
Mailing Address - Phone:573-722-5261
Mailing Address - Fax:573-722-3650
Practice Address - Street 1:106 FARRAR DR
Practice Address - Street 2:SUITE 109
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-4902
Practice Address - Country:US
Practice Address - Phone:573-334-7055
Practice Address - Fax:573-334-7961
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1126162084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF73348Medicare UPIN
MO000094037Medicare ID - Type UnspecifiedMEDICARE PART B NUMBER