Provider Demographics
NPI:1346324746
Name:DAVIS, BRADLEY J (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:J
Last Name:DAVIS
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 1:8715 MASSEY CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7127
Mailing Address - Country:US
Mailing Address - Phone:719-313-2144
Mailing Address - Fax:
Practice Address - Street 1:8715 MASSEY CIR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7127
Practice Address - Country:US
Practice Address - Phone:719-313-2144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO469622084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTG05308Medicare UPIN
COCO307264Medicare PIN