Provider Demographics
NPI:1689684284
Name:DILLARD, BRADLEY EARL (BA)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:EARL
Last Name:DILLARD
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 GRANT RD NE
Mailing Address - Street 2:
Mailing Address - City:ARMUCHEE
Mailing Address - State:GA
Mailing Address - Zip Code:30105-2618
Mailing Address - Country:US
Mailing Address - Phone:706-673-9743
Mailing Address - Fax:
Practice Address - Street 1:2409 HOMER CLAYTON DR
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-2207
Practice Address - Country:US
Practice Address - Phone:256-582-3203
Practice Address - Fax:256-582-3216
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51522613OtherBCBS