Provider Demographics
NPI:1568421683
Name:DUBOIS, BRADLEY M (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:M
Last Name:DUBOIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1100 REID PKWY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-825-0511
Mailing Address - Fax:765-827-1247
Practice Address - Street 1:1473 E STATE ROAD 44
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-8374
Practice Address - Country:US
Practice Address - Phone:765-825-0511
Practice Address - Fax:765-827-1247
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045453A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200184980Medicaid
INANTHEMOther000000969484
IN259370105Medicare PIN
IN200184980Medicaid