Provider Demographics
NPI:1245204809
Name:BRADLEY, KATRINA SUZANNE (MD)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:SUZANNE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W 90TH ST APT 12F
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-1236
Mailing Address - Country:US
Mailing Address - Phone:646-425-3935
Mailing Address - Fax:
Practice Address - Street 1:232 WEST 80TH STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024
Practice Address - Country:US
Practice Address - Phone:646-962-3020
Practice Address - Fax:646-962-3020
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY232265-1207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02667403Medicaid
NY730C91U991Medicare PIN
I18860Medicare UPIN