Provider Demographics
NPI:1275558249
Name:STUFFLEBAM, BRADLEY C (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:C
Last Name:STUFFLEBAM
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 1:629 SABLE DR
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-4472
Mailing Address - Country:US
Mailing Address - Phone:618-533-0727
Mailing Address - Fax:
Practice Address - Street 1:629 SABLE DR
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-4472
Practice Address - Country:US
Practice Address - Phone:618-533-0727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0588472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-058847OtherSTATE LICENSE #
BS0982795OtherDEA #
IL036-058847OtherSTATE LICENSE #