Provider Demographics
NPI:1609955459
Name:MARTIN, BRADLEY JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JOHN
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60480-1613
Mailing Address - Country:US
Mailing Address - Phone:780-833-4480
Mailing Address - Fax:708-839-1323
Practice Address - Street 1:161 MARKET ST
Practice Address - Street 2:
Practice Address - City:WILLOW SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60480-1613
Practice Address - Country:US
Practice Address - Phone:780-833-4480
Practice Address - Fax:708-839-1323
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK22576Medicare ID - Type UnspecifiedDR BRADLEY JOHN MARTIN