Provider Demographics
NPI:1558476739
Name:BUCKROP, BRADLEY WILLIAM (DPM)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:WILLIAM
Last Name:BUCKROP
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3727 46TH AVE
Mailing Address - Street 2:STE 103
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-7078
Mailing Address - Country:US
Mailing Address - Phone:309-788-3668
Mailing Address - Fax:309-786-5168
Practice Address - Street 1:3727 46TH AVENUE BLACKHAWK RD
Practice Address - Street 2:STE 103
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-7078
Practice Address - Country:US
Practice Address - Phone:309-788-3668
Practice Address - Fax:309-786-5168
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004658213EP1101X
IA00545213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL0101OtherJOHN DEERE HEALTH
IL8182069OtherBCBS
IA00545OtherIOWA DEPT OF PUBLIC HLTH
IL016004658Medicaid
480024844OtherJURISDICTION B DME MAC
480024844OtherJURISDICTION B DME MAC
U33388Medicare UPIN
IL016004658Medicaid
IL8182069OtherBCBS