Provider Demographics
NPI:1336308261
Name:BRADFORD, DREW PORTER
Entity Type:Individual
Prefix:
First Name:DREW
Middle Name:PORTER
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25747 BUTTERNUT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-4507
Mailing Address - Country:US
Mailing Address - Phone:440-759-5228
Mailing Address - Fax:
Practice Address - Street 1:25747 BUTTERNUT RIDGE RD
Practice Address - Street 2:
Practice Address - City:NORTH OLMSTED
Practice Address - State:OH
Practice Address - Zip Code:44070-4507
Practice Address - Country:US
Practice Address - Phone:440-759-5228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2402635Medicaid