Provider Demographics
NPI:1538125745
Name:IDELSHON, BRADLEY CURTIS (DO)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:CURTIS
Last Name:IDELSHON
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 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:805-361-8028
Mailing Address - Fax:805-361-8097
Practice Address - Street 1:1057 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-2504
Practice Address - Country:US
Practice Address - Phone:805-270-1700
Practice Address - Fax:805-481-7097
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5884207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC71031FMedicaid
CAFHC71032FMedicaid
CAHAP71031FOtherFAMILY PACK
CAAY679XMedicare PIN
CAW1508DMedicare Oscar/Certification
CAFHC71031FMedicaid
CAFHC71032FMedicaid
CA551983Medicare Oscar/Certification
CAAY679YMedicare PIN
CAW1508Medicare PIN
CAHAP71031FOtherFAMILY PACK
CA020A58841Medicare ID - Type Unspecified
CA551977Medicare Oscar/Certification