Provider Demographics
NPI:1528018470
Name:ANDERSEN, BRADLEY T (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:T
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3660 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3912
Mailing Address - Country:US
Mailing Address - Phone:951-697-5615
Mailing Address - Fax:951-697-5687
Practice Address - Street 1:6405 DAY ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0901
Practice Address - Country:US
Practice Address - Phone:951-697-5615
Practice Address - Fax:951-697-5687
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA89184207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ31887ZOtherBILLING LOCATION
CA1780782557OtherSITE NPI