Provider Demographics
NPI:1497046049
Name:SCOGGINS, BRADLEY J (DO)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:J
Last Name:SCOGGINS
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 1:407 S. SCHWARTZ STE 102
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-3901
Mailing Address - Country:US
Mailing Address - Phone:505-609-9700
Mailing Address - Fax:
Practice Address - Street 1:407 S SCHWARTZ AVE STE 102
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5925
Practice Address - Country:US
Practice Address - Phone:505-609-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-29
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1790-13208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics