Provider Demographics
NPI:1497798854
Name:BOOTSTAYLOR, BRADFORD (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:
Last Name:BOOTSTAYLOR
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 1:285 BOULEVARD NE STE 345A
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-4205
Mailing Address - Country:US
Mailing Address - Phone:404-618-6825
Mailing Address - Fax:404-480-3876
Practice Address - Street 1:600 W PEACHTREE ST NW
Practice Address - Street 2:SUITE 500
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-3607
Practice Address - Country:US
Practice Address - Phone:404-475-0816
Practice Address - Fax:404-875-7102
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041733208VP0000X, 207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000702996HMedicaid
GA000702996QMedicaid
GA000702996TMedicaid
GA000702996GMedicaid
GA000702996JMedicaid
GA000702996KMedicaid
GA000702996VMedicaid
GA000702996FMedicaid
GA000702996SMedicaid