Provider Demographics
NPI:1689669301
Name:BRADLEY, DOUGLAS L (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:L
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17067 S OUTER RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BELTON
Mailing Address - State:MO
Mailing Address - Zip Code:64012-2165
Mailing Address - Country:US
Mailing Address - Phone:816-331-4000
Mailing Address - Fax:816-331-3626
Practice Address - Street 1:17067 S OUTER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BELTON
Practice Address - State:MO
Practice Address - Zip Code:64012-2165
Practice Address - Country:US
Practice Address - Phone:816-331-4000
Practice Address - Fax:816-331-3626
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOMD R5B55207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201536331Medicaid
MO1689669301Medicaid
KS100452540AMedicaid
MO1689669301Medicaid
KSN966298Medicare PIN
MO201536331Medicaid