Provider Demographics
NPI:1629414016
Name:BRADLEY, SEAN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:MICHAEL
Last Name:BRADLEY
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 1:402 N TEJON ST # 200
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1142
Mailing Address - Country:US
Mailing Address - Phone:719-633-3850
Mailing Address - Fax:
Practice Address - Street 1:402 N TEJON ST # 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1142
Practice Address - Country:US
Practice Address - Phone:719-633-3850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0056760208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program