Provider Demographics
NPI: | 1508910894 |
---|---|
Name: | BRADLEY, ROBERT CLAUD (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | ROBERT |
Middle Name: | CLAUD |
Last Name: | BRADLEY |
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: | 1455 MAIN ST |
Mailing Address - Street 2: | SUITE 200 |
Mailing Address - City: | WINDSOR |
Mailing Address - State: | CO |
Mailing Address - Zip Code: | 80550-5559 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 970-686-3950 |
Mailing Address - Fax: | 970-686-3960 |
Practice Address - Street 1: | 1455 MAIN ST |
Practice Address - Street 2: | SUITE 100 |
Practice Address - City: | WINDSOR |
Practice Address - State: | CO |
Practice Address - Zip Code: | 80550-5559 |
Practice Address - Country: | US |
Practice Address - Phone: | 970-686-3950 |
Practice Address - Fax: | 970-686-3960 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-01-23 |
Last Update Date: | 2015-01-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CO | 19366 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CO | 1193663 | Medicaid | |
CO | P00944651 | Other | MEDICARE RAILROAD CARRIER PTAN |
CO | CO307289 | Medicare PIN | |
D23593 | Medicare UPIN | ||
CO | 1193663 | Medicaid | |
C173658 | Medicare PIN | ||
C289718 | Medicare PIN |