Provider Demographics
NPI:1558358234
Name:BRADLEY, CANDACE ANGELENA (DO)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:ANGELENA
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 EAST KINGS HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-5201
Mailing Address - Country:US
Mailing Address - Phone:336-623-9711
Mailing Address - Fax:336-623-6182
Practice Address - Street 1:117 EAST KINGS HIGHWAY
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5201
Practice Address - Country:US
Practice Address - Phone:336-623-9711
Practice Address - Fax:336-623-6182
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200200649207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89133CMedicaid
NC89133C4Medicaid
NCH79571Medicare UPIN
NC2401285Medicare ID - Type Unspecified