Provider Demographics
NPI:1366461998
Name:BRADLEY, JOAN E (DPM)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:E
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-605-7974
Mailing Address - Fax:858-605-7349
Practice Address - Street 1:15004 INNOVATION DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3491
Practice Address - Country:US
Practice Address - Phone:858-605-7974
Practice Address - Fax:858-605-7349
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAT11655213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E33640Medicaid
CAWE3364DMedicare PIN
CA000E33640Medicaid