Provider Demographics
NPI:1417998063
Name:BRADEEN, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BRADEEN
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 1:231 ATLANTIC ST UNIT 61
Mailing Address - Street 2:
Mailing Address - City:KEYPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:07735-2045
Mailing Address - Country:US
Mailing Address - Phone:207-236-0646
Mailing Address - Fax:
Practice Address - Street 1:4 GLEN COVE DR
Practice Address - Street 2:SUITE 5
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-4235
Practice Address - Country:US
Practice Address - Phone:207-921-5880
Practice Address - Fax:207-921-5883
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME10193207R00000X
NH13237207R00000X
MEMD10193208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHB86756Medicare UPIN
NHRE8879Medicare PIN
NH01Y010683NH01OtherBCBS
NHB86756Medicare UPIN