Provider Demographics
NPI:1497724041
Name:BRADLEY-LEBOEUF, MARY L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:BRADLEY-LEBOEUF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 LYNN LN
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-6845
Mailing Address - Country:US
Mailing Address - Phone:580-286-5437
Mailing Address - Fax:580-286-3955
Practice Address - Street 1:1307 LYNN LN
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-6845
Practice Address - Country:US
Practice Address - Phone:580-286-5437
Practice Address - Fax:580-286-3955
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22507208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100187600BMedicaid
OK22507OtherSTATE MED LICENSE
H12755Medicare UPIN