Provider Demographics
NPI:1104866714
Name:BRADSHAW, CHARLES MARSHALL (MD, PA)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MARSHALL
Last Name:BRADSHAW
Suffix:
Gender:M
Credentials:MD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:601 OMEGA DR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76014-2075
Mailing Address - Country:US
Mailing Address - Phone:817-465-5881
Mailing Address - Fax:817-465-6336
Practice Address - Street 1:2941 OAK PARK CIR STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-1852
Practice Address - Country:US
Practice Address - Phone:817-332-7433
Practice Address - Fax:817-394-6282
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD2367174400000X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB101634Medicare PIN
TX029858001Medicare ID - Type UnspecifiedMEDICARE NUMBER
TX75-1479847OtherTAX IDENTIFICATION NUMBER
TXP000235L2Medicaid