Provider Demographics
NPI:1629070636
Name:BRADFORD, VELMA SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:VELMA
Middle Name:SUSAN
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:BRADFORD
Other - Last Name:LOWERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:777 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9251
Mailing Address - Country:US
Mailing Address - Phone:208-514-2500
Mailing Address - Fax:208-375-2217
Practice Address - Street 1:8610 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1645
Practice Address - Country:US
Practice Address - Phone:208-954-8711
Practice Address - Fax:208-375-2217
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7541173000000X
IDM-7541208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805219300Medicaid
ID1629070636Medicaid