Provider Demographics
NPI:1659698991
Name:HART, BRADLEY (DPM)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:HART
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-772-8772
Mailing Address - Fax:607-772-8796
Practice Address - Street 1:65 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-1651
Practice Address - Country:US
Practice Address - Phone:607-772-8772
Practice Address - Fax:607-772-8796
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY006571213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03686931Medicaid
NYJ400090449Medicare PIN