Provider Demographics
NPI:1366444648
Name:STEPHENS, BRADFORD JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:JAY
Last Name:STEPHENS
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 1:202 A SW
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354
Mailing Address - Country:US
Mailing Address - Phone:918-541-9400
Mailing Address - Fax:918-541-9411
Practice Address - Street 1:202 A SW
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354
Practice Address - Country:US
Practice Address - Phone:918-541-9400
Practice Address - Fax:918-541-9411
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2023-03-07
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
OK18454174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100048810AMedicaid
OK5975535OtherAETNA PROVIDER NUMBER
OK37D1002186OtherCLIA WAIVE NUMBER
OKP00066051OtherRAILROD MEDICARE PROVIDER
OKP00066051OtherRAILROD MEDICARE PROVIDER
OK37D1002186OtherCLIA WAIVE NUMBER