Provider Demographics
NPI:1457302135
Name:MCDONALD, BRADLEY ALLWIN (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:ALLWIN
Last Name:MCDONALD
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 1:14724 480TH AVE
Mailing Address - Street 2:
Mailing Address - City:MILBANK
Mailing Address - State:SD
Mailing Address - Zip Code:57252-5925
Mailing Address - Country:US
Mailing Address - Phone:605-432-5852
Mailing Address - Fax:
Practice Address - Street 1:819 ASH ST
Practice Address - Street 2:
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801-1201
Practice Address - Country:US
Practice Address - Phone:715-635-2111
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39414-020207Q00000X
MN40575207Q00000X
SD4366207Q00000X
IA30546207Q00000X
ND9796207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32456200Medicaid
WI32456200Medicaid