Provider Demographics
NPI:1124000518
Name:BRADSHAW, JOHN ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANDREW
Last Name:BRADSHAW
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 1:10 GRAHAM RD W
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1055
Mailing Address - Country:US
Mailing Address - Phone:607-257-2188
Mailing Address - Fax:607-266-7341
Practice Address - Street 1:10 GRAHAM RD W
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1055
Practice Address - Country:US
Practice Address - Phone:607-257-2188
Practice Address - Fax:607-266-7341
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216716208000000X, 2080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10867OtherTOTALCARE/MANAGED MA
000136319OtherBLUE SHIELD/HMO/EXCELLUS
NY02223650Medicaid
00920290002OtherHEALTH NOW
V018315OtherTRICARE
161010811OtherRMSCO
161010811OtherCOMMERCIAL CARRIERS
NY02223650Medicaid