Provider Demographics
NPI:1649230012
Name:PADDOCK, BRADLEY HOLMES (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:HOLMES
Last Name:PADDOCK
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 1:242 E STATE ST EXT
Mailing Address - Street 2:
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-6039
Mailing Address - Country:US
Mailing Address - Phone:518-725-8656
Mailing Address - Fax:
Practice Address - Street 1:182 STEELE AVE LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-4617
Practice Address - Country:US
Practice Address - Phone:518-725-8656
Practice Address - Fax:518-773-7824
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150053207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400554086OtherMEDICARE PIN-NLH
NY00709682Medicaid
NY00709682Medicaid
NY53370AMedicare PIN
NY53370BMedicare PIN