Provider Demographics
NPI:1528369592
Name:KENESON, BRADLEY JAMES (DO)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JAMES
Last Name:KENESON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 OLD CLEBURNE RD
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-1422
Mailing Address - Country:US
Mailing Address - Phone:682-936-2544
Mailing Address - Fax:
Practice Address - Street 1:806 OLD CLEBURNE RD
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-1422
Practice Address - Country:US
Practice Address - Phone:682-999-1173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-08
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN6899207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX219211401Medicaid
TXP00957426OtherRAILROAD
TX8CQ572OtherBCBS
TX219211402Medicaid
TX8EH374OtherBCBS TX
TXTXB118264Medicare PIN
TX8CQ572OtherBCBS