Provider Demographics
NPI:1508474917
Name:BRADFORD, CHAUNCEY
Entity Type:Individual
Prefix:
First Name:CHAUNCEY
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 E MAIN ST STE 207A-1
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-9071
Mailing Address - Country:US
Mailing Address - Phone:480-477-9199
Mailing Address - Fax:
Practice Address - Street 1:1616 E MAIN ST STE 207A-1
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-9071
Practice Address - Country:US
Practice Address - Phone:480-477-9199
Practice Address - Fax:480-477-9199
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ503836Medicaid