Provider Demographics
NPI:1659437028
Name:BRADLEY, MARK VINCENT (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:VINCENT
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 1:333 W 56TH ST
Mailing Address - Street 2:SUITE 1F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-3764
Mailing Address - Country:US
Mailing Address - Phone:212-582-1933
Mailing Address - Fax:
Practice Address - Street 1:423 E 23RD ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-5011
Practice Address - Country:US
Practice Address - Phone:212-686-7500
Practice Address - Fax:212-951-6357
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2256202084P0015X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI39878Medicare UPIN
NY538BL1Medicare ID - Type Unspecified