Provider Demographics
NPI:1609850122
Name:LINDSTROM, BRAD A (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:A
Last Name:LINDSTROM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E BUTLER RD
Mailing Address - Street 2:SUITE A-2
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-2169
Mailing Address - Country:US
Mailing Address - Phone:864-281-9171
Mailing Address - Fax:864-281-9170
Practice Address - Street 1:211 E BUTLER RD
Practice Address - Street 2:SUITE A-2
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2169
Practice Address - Country:US
Practice Address - Phone:864-281-9171
Practice Address - Fax:864-281-9170
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC555213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC735550Medicaid
SC735550Medicaid