Provider Demographics
NPI:1689646374
Name:BRADLEY, DAVID DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:DANIEL
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 1:2460 LEE HWY N
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:VA
Mailing Address - Zip Code:24301-2335
Mailing Address - Country:US
Mailing Address - Phone:540-980-8804
Mailing Address - Fax:540-980-8161
Practice Address - Street 1:2460 LEE HWY N
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:VA
Practice Address - Zip Code:24301-2335
Practice Address - Country:US
Practice Address - Phone:540-980-8804
Practice Address - Fax:540-980-8161
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101228716207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5844461Medicaid
H18785Medicare UPIN
VA5844461Medicaid