Provider Demographics
NPI:1164462602
Name:GARNER, BRADFORD P (MD)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:P
Last Name:GARNER
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:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-820-0289
Mailing Address - Fax:417-820-0437
Practice Address - Street 1:550 S HUDSON AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MO
Practice Address - Zip Code:65605-2362
Practice Address - Country:US
Practice Address - Phone:417-678-5176
Practice Address - Fax:417-678-0675
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS6533207Q00000X
MO2009001435207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS105594OtherBLUE CROSS BLUE SHIELD
431560263OtherTRICARE WEST
P00748476OtherRAILROAD MEDICARE
MO1164462602Medicaid
KS105594OtherBLUE CROSS BLUE SHIELD
P00748476OtherRAILROAD MEDICARE