Provider Demographics
NPI:1578858288
Name:CHAMPAGNE, BRADLEY PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:PAUL
Last Name:CHAMPAGNE
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 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:337-233-0219
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:102 DRURY LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-5702
Practice Address - Country:US
Practice Address - Phone:337-233-0219
Practice Address - Fax:337-233-2418
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA206155208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
600535AI32OtherMEDICARE
LA2147846Medicaid
LAINTERNMedicaid