Provider Demographics
NPI:1407867658
Name:MELVILLE, BRADLEY R (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:R
Last Name:MELVILLE
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:PO BOX 5546
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5546
Mailing Address - Country:US
Mailing Address - Phone:801-475-3500
Mailing Address - Fax:
Practice Address - Street 1:4403 HARRISON BLVD STE 1875
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3325
Practice Address - Country:US
Practice Address - Phone:801-732-5900
Practice Address - Fax:801-732-5989
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT176580-1205208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000004812Medicare PIN
UTD87689Medicare UPIN