Provider Demographics
NPI:1407015282
Name:BRADFORD L TALCOTT MD PHD PC
Entity Type:Organization
Organization Name:BRADFORD L TALCOTT MD PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:L
Authorized Official - Last Name:TALCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD
Authorized Official - Phone:208-552-4823
Mailing Address - Street 1:2353 CORONADO ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7407
Mailing Address - Country:US
Mailing Address - Phone:208-552-4823
Mailing Address - Fax:208-552-4856
Practice Address - Street 1:2353 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7407
Practice Address - Country:US
Practice Address - Phone:208-552-4823
Practice Address - Fax:208-552-4856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM100442084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty