Provider Demographics
NPI:1578521522
Name:STAEHLE, BRADLEY HAROLD (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:HAROLD
Last Name:STAEHLE
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 1:19 WOODLAND ST
Mailing Address - Street 2:SUITE 15
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-2372
Mailing Address - Country:US
Mailing Address - Phone:860-522-1101
Mailing Address - Fax:860-549-7092
Practice Address - Street 1:19 WOODLAND ST
Practice Address - Street 2:SUITE 15
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-2372
Practice Address - Country:US
Practice Address - Phone:860-522-1101
Practice Address - Fax:860-549-7092
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0421592085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001421594Medicaid
CTH46555Medicare UPIN
CT300003541Medicare ID - Type Unspecified