Provider Demographics
NPI:1356448450
Name:ELLIOTT, BRADLEY JESSE (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JESSE
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 PLANK RD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-2020
Mailing Address - Country:US
Mailing Address - Phone:518-383-4889
Mailing Address - Fax:518-383-4892
Practice Address - Street 1:677 PLANK RD
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-2020
Practice Address - Country:US
Practice Address - Phone:518-383-4889
Practice Address - Fax:518-383-4892
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX005543-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY51264BMedicare ID - Type UnspecifiedMEDICARE