Provider Demographics
NPI:1619241346
Name:MARK W BRADFORD MD INC PS
Entity Type:Organization
Organization Name:MARK W BRADFORD MD INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-459-7713
Mailing Address - Street 1:3624 ENSIGN RD NE STE D
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5074
Mailing Address - Country:US
Mailing Address - Phone:360-459-7713
Mailing Address - Fax:360-459-5441
Practice Address - Street 1:3624 ENSIGN RD NE STE D
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5074
Practice Address - Country:US
Practice Address - Phone:360-459-7713
Practice Address - Fax:360-459-5441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD0019897261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center