Provider Demographics
NPI:1629336128
Name:BRADFORD, BENJAMIN DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:DANIEL
Last Name:BRADFORD
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 5910
Mailing Address - Street 2:
Mailing Address - City:STATELINE
Mailing Address - State:NV
Mailing Address - Zip Code:89449-5910
Mailing Address - Country:US
Mailing Address - Phone:775-588-5000
Mailing Address - Fax:
Practice Address - Street 1:276 KINGSBURY GRADE # 101
Practice Address - Street 2:
Practice Address - City:STATELINE
Practice Address - State:NV
Practice Address - Zip Code:89449-9804
Practice Address - Country:US
Practice Address - Phone:775-588-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-03
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV22619207N00000X, 207YX0007X, 2086S0122X, 207YS0123X
CAA126409207YS0123X
NY286986207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery