Provider Demographics
NPI:1609863760
Name:BUNDRANT, BRADLY (MD)
Entity Type:Individual
Prefix:
First Name:BRADLY
Middle Name:
Last Name:BUNDRANT
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 617
Mailing Address - Street 2:
Mailing Address - City:BALLINGER
Mailing Address - State:TX
Mailing Address - Zip Code:76821-0617
Mailing Address - Country:US
Mailing Address - Phone:325-365-5737
Mailing Address - Fax:325-365-2405
Practice Address - Street 1:2001 HUTCHINS AVE STE C
Practice Address - Street 2:
Practice Address - City:BALLINGER
Practice Address - State:TX
Practice Address - Zip Code:76821-4453
Practice Address - Country:US
Practice Address - Phone:325-365-5737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7275207P00000X, 207QS1201X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0066DNOtherBCBS
TX139813338Medicaid
TXH7275Other207P00000X
TX139813304Medicaid
TX139813338Medicaid
TX8L2448Medicare PIN
TX00F53XMedicare PIN
458867Medicare PIN
TX00L22SMedicare PIN
TX139813304Medicaid
TX00732ZMedicare PIN