Provider Demographics
NPI:1326031964
Name:STRAKA, BRADLEY THEODORE JOHN (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:THEODORE JOHN
Last Name:STRAKA
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 1:2607 N GRANDVIEW BLVD
Mailing Address - Street 2:STE 125
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1686
Mailing Address - Country:US
Mailing Address - Phone:262-290-4540
Mailing Address - Fax:262-229-2220
Practice Address - Street 1:2607 N GRANDVIEW BLVD
Practice Address - Street 2:STE 125
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1686
Practice Address - Country:US
Practice Address - Phone:414-455-0919
Practice Address - Fax:414-455-0905
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2017-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44600020207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34279600Medicaid
WI070017188OtherRAILROAD MEDICARE
WI070017187OtherRAILROAD MEDICARE
WI$$$$$$$$$000OtherBLUESHIELD
WI000802325Medicare PIN
WI$$$$$$$$$000OtherBLUESHIELD
WI000568449Medicare PIN
WI070017188OtherRAILROAD MEDICARE
WI34279600Medicaid