Provider Demographics
NPI:1508971003
Name:BRADFORD, JOHN HOWARD (MSPT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:HOWARD
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 COTTAGE RD
Mailing Address - Street 2:
Mailing Address - City:BOZRAH
Mailing Address - State:CT
Mailing Address - Zip Code:06334-1412
Mailing Address - Country:US
Mailing Address - Phone:860-608-2773
Mailing Address - Fax:
Practice Address - Street 1:11 CENTRE ST
Practice Address - Street 2:SUITE 6&7
Practice Address - City:SALEM
Practice Address - State:CT
Practice Address - Zip Code:06420-3844
Practice Address - Country:US
Practice Address - Phone:860-949-2561
Practice Address - Fax:860-471-8388
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006963225100000X
AZ8020225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004221868-02Medicaid