Provider Demographics
NPI:1255693503
Name:BARHAM, BRADLEY ALLEN (DO)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:ALLEN
Last Name:BARHAM
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 1:1850 HICKORY ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79601-2334
Mailing Address - Country:US
Mailing Address - Phone:325-677-2801
Mailing Address - Fax:325-677-9110
Practice Address - Street 1:1850 HICKORY ST
Practice Address - Street 2:SUITE 102
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-2334
Practice Address - Country:US
Practice Address - Phone:325-677-2801
Practice Address - Fax:325-677-9110
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ3146208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX346198001Medicaid
8FA310OtherBCBS
411887YUC3Medicare PIN