Provider Demographics
NPI:1114168796
Name:BRADLEY, EDWARD B (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:B
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 1:1904 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-5662
Mailing Address - Country:US
Mailing Address - Phone:315-793-8856
Mailing Address - Fax:315-793-8307
Practice Address - Street 1:1904 GENESEE STREET
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13505-8150
Practice Address - Country:US
Practice Address - Phone:315-793-8856
Practice Address - Fax:315-793-8307
Is Sole Proprietor?:No
Enumeration Date:2009-03-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY086168207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE15712Medicare UPIN