Provider Demographics
NPI:1346241197
Name:BRADY, JOHN W (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:BRADY
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 1:4001 LEAVENWORTH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68105-1026
Mailing Address - Country:US
Mailing Address - Phone:605-665-7841
Mailing Address - Fax:605-665-0546
Practice Address - Street 1:1104 W 8TH ST
Practice Address - Street 2:
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-3306
Practice Address - Country:US
Practice Address - Phone:605-665-7841
Practice Address - Fax:605-665-0546
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE26532207Q00000X
SD4085207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5602683Medicaid
SD5602683Medicaid
SDS6417Medicare PIN