Provider Demographics
NPI:1255321204
Name:DAVIS, BRADLEY GARTH (DO)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:GARTH
Last Name:DAVIS
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 1:3700 MALL VIEW RD
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93306-3050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3700 MALL VIEW RD
Practice Address - Street 2:MEDICAL STAFF OFFICE
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93306-3050
Practice Address - Country:US
Practice Address - Phone:661-328-9831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5494207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX54940Medicaid
CA00AX54940Medicaid
F01639Medicare UPIN