Provider Demographics
NPI:1679792196
Name:MUTCHLER, BRADFORD ELROD (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:ELROD
Last Name:MUTCHLER
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 1:1219 N. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:KY
Mailing Address - Zip Code:42320
Mailing Address - Country:US
Mailing Address - Phone:270-274-1800
Mailing Address - Fax:270-274-5600
Practice Address - Street 1:1219 N. MAIN ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:KY
Practice Address - Zip Code:42320
Practice Address - Country:US
Practice Address - Phone:270-274-1800
Practice Address - Fax:270-274-5600
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY133942083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64133945Medicaid
KYC67492Medicare UPIN
KY64133945Medicaid