Provider Demographics
NPI:1447214309
Name:BRADLEY, MARK W (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3601 S 6TH AVE
Mailing Address - Street 2:BLDG 90 (4-116D)
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85723-0001
Mailing Address - Country:US
Mailing Address - Phone:520-792-1450
Mailing Address - Fax:520-629-1864
Practice Address - Street 1:3601 S 6TH AVE
Practice Address - Street 2:BLDG 90 (4-116D)
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85723-0001
Practice Address - Country:US
Practice Address - Phone:520-792-1450
Practice Address - Fax:520-629-1864
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01035245A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100052620Medicaid
IN100052620Medicaid
E03604Medicare UPIN
IN090540BBMedicare ID - Type Unspecified
IN187230Medicare ID - Type UnspecifiedMITCHELL