Provider Demographics
NPI:1427016575
Name:BRADLEY, MARK R (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:BRADLEY
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 1:110 LONE OAK LN
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53027-2600
Mailing Address - Country:US
Mailing Address - Phone:262-670-1800
Mailing Address - Fax:
Practice Address - Street 1:110 LONE OAK LN
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027-2600
Practice Address - Country:US
Practice Address - Phone:262-670-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39261207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30090300Medicaid
WI80060Medicare ID - Type Unspecified
WI30090300Medicaid