Provider Demographics
NPI:1346221082
Name:BASTOW, BRADLEY D (DO)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:D
Last Name:BASTOW
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 1:950 BLUE STAR HWY
Mailing Address - Street 2:SUITE 1-2
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-7759
Mailing Address - Country:US
Mailing Address - Phone:269-637-1388
Mailing Address - Fax:269-637-1459
Practice Address - Street 1:950 BLUE STAR HWY
Practice Address - Street 2:SUITE 1-2
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-7759
Practice Address - Country:US
Practice Address - Phone:269-637-1388
Practice Address - Fax:269-637-1459
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008849207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3449722Medicaid
MIOM58120Medicare ID - Type Unspecified
MIE33118Medicare UPIN