Provider Demographics
NPI:1407885924
Name:STOLTZ, BRAD (DO)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:
Last Name:STOLTZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 E STREET RD
Mailing Address - Street 2:
Mailing Address - City:TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-7711
Mailing Address - Country:US
Mailing Address - Phone:215-464-4111
Mailing Address - Fax:267-574-8111
Practice Address - Street 1:339 E STREET RD
Practice Address - Street 2:
Practice Address - City:TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-7711
Practice Address - Country:US
Practice Address - Phone:215-464-4111
Practice Address - Fax:267-574-8111
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007651L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01526143Medicaid
PA734984Medicare ID - Type Unspecified
PA01526143Medicaid