Provider Demographics
NPI:1518968460
Name:BRADSHAW, TODD M (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:M
Last Name:BRADSHAW
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 1:225 MEMORIAL DR STE 1200
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:54923-1243
Mailing Address - Country:US
Mailing Address - Phone:920-361-5770
Mailing Address - Fax:920-361-5779
Practice Address - Street 1:225 MEMORIAL DR STE 1200
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1243
Practice Address - Country:US
Practice Address - Phone:920-361-5770
Practice Address - Fax:920-361-5779
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36541-020207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32152000Medicaid
WIF87976Medicare UPIN
WI32152000Medicaid