Provider Demographics
NPI:1134501646
Name:GADDIS, BRADLEY (DO)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:GADDIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9513 LAKE HUGH DR
Mailing Address - Street 2:
Mailing Address - City:GOTHA
Mailing Address - State:FL
Mailing Address - Zip Code:34734-4630
Mailing Address - Country:US
Mailing Address - Phone:205-310-8812
Mailing Address - Fax:
Practice Address - Street 1:10000 W COLONIAL DR STE 393
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-3433
Practice Address - Country:US
Practice Address - Phone:407-296-1871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS16558208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program