Provider Demographics
NPI:1639294259
Name:BRADLEY, DAVID D (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:D
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:400 E THIRD STREET MCL2CRED
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-3146
Mailing Address - Fax:
Practice Address - Street 1:ESSENTIA HEALTH SOUTH UNIVERSITY CLINIC
Practice Address - Street 2:1702 UNIVERSITY DRIVE SOUTH
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:701-364-3300
Practice Address - Fax:701-364-8906
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN52167208100000X
NDPT14574208100000X
ND14574208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN864638100Medicaid
MN090000042Medicare PIN