Provider Demographics
NPI:1538329750
Name:BRADLEY J FOLKESTAD, MD, LTD
Entity Type:Organization
Organization Name:BRADLEY J FOLKESTAD, MD, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:FOLKESTAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-561-7250
Mailing Address - Street 1:18699 N 67TH AVE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7140
Mailing Address - Country:US
Mailing Address - Phone:623-561-7250
Mailing Address - Fax:623-561-0098
Practice Address - Street 1:18699 N 67TH AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7140
Practice Address - Country:US
Practice Address - Phone:623-561-7250
Practice Address - Fax:623-561-0098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19824207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ106246Medicaid
AZ106246Medicaid
AZF08785Medicare UPIN