Provider Demographics
NPI:1164656542
Name:DEMPSEY, BRADLEY GLEN (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:GLEN
Last Name:DEMPSEY
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 1:902 LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3597
Mailing Address - Country:US
Mailing Address - Phone:719-557-5855
Mailing Address - Fax:719-557-5097
Practice Address - Street 1:902 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3597
Practice Address - Country:US
Practice Address - Phone:719-557-5855
Practice Address - Fax:719-557-5097
Is Sole Proprietor?:No
Enumeration Date:2009-05-13
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6206207Q00000X
390200000X
CODR.0052763207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO313101YSS8OtherMEDICARE PTAN
COP01528181OtherMEDICARE RAILROAD
CO97055280Medicaid