Provider Demographics
NPI:1497786867
Name:BRADLEY, MARK STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STEPHEN
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 ASPEN DR STE 500B
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5495
Mailing Address - Country:US
Mailing Address - Phone:505-466-2575
Mailing Address - Fax:505-466-2575
Practice Address - Street 1:1925 ASPEN DR STE 500B
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5495
Practice Address - Country:US
Practice Address - Phone:505-466-2575
Practice Address - Fax:505-466-2575
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2009-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2002-0015207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM85327760Medicaid
NM400109OtherMEDICARE INDIVIDUAL PTAN
NMNMB2257Medicare PIN
NME96862Medicare UPIN