Provider Demographics
NPI:1144424748
Name:BIRT, BRADLEY BLAIR (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:BLAIR
Last Name:BIRT
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 1:20320 NORTHWEST FWY
Mailing Address - Street 2:SUITE 900
Mailing Address - City:JERSEY VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:77065-5641
Mailing Address - Country:US
Mailing Address - Phone:281-453-7232
Mailing Address - Fax:281-440-2020
Practice Address - Street 1:16750 RED OAK DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-2543
Practice Address - Country:US
Practice Address - Phone:281-453-7110
Practice Address - Fax:281-440-2020
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP1-0026278207RA0000X
TXN42992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
3851910300OtherMYUTMB 3851910300-COMMERCIAL NUMBER