Provider Demographics
NPI:1518958743
Name:DEAL, BRADLEY KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:KENNETH
Last Name:DEAL
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 1:13 MAIN STREET
Mailing Address - Street 2:SAN QUENTIN PRISON
Mailing Address - City:SAN QUENTIN
Mailing Address - State:CA
Mailing Address - Zip Code:94964
Mailing Address - Country:US
Mailing Address - Phone:415-454-1460
Mailing Address - Fax:
Practice Address - Street 1:13 MAIN ST.
Practice Address - Street 2:SAN QUENTIN PRISON
Practice Address - City:SAN QUENTIN
Practice Address - State:CA
Practice Address - Zip Code:94964
Practice Address - Country:US
Practice Address - Phone:415-454-1460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-05
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME940462084P0800X, 2084P0804X
CAA1025302084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276684100Medicaid
FLA36155Medicare ID - Type Unspecified
FL276684100Medicaid