Provider Demographics
NPI:1558479352
Name:BRADLEY, KENNETH STERLING (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:STERLING
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2129
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES PENINSULA
Mailing Address - State:CA
Mailing Address - Zip Code:90274-8129
Mailing Address - Country:US
Mailing Address - Phone:310-540-9888
Mailing Address - Fax:310-540-0444
Practice Address - Street 1:4201 TORRANCE BLVD
Practice Address - Street 2:SUITE 590
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4536
Practice Address - Country:US
Practice Address - Phone:310-540-9888
Practice Address - Fax:310-540-0444
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10347207L00000X
CAG82005207L00000X, 208VP0000X
MI4301079245207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100503440Medicaid
NVP00170873OtherRAILROAD MEDICARE
NVCC9142OtherBC
NV37597Medicare PIN
NV100503440Medicaid
NVCC9142OtherBC