Provider Demographics
NPI:1689899510
Name:BRADFORD, JOSHUA (DO)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-2003
Mailing Address - Country:US
Mailing Address - Phone:304-768-8500
Mailing Address - Fax:304-768-8530
Practice Address - Street 1:707 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-2003
Practice Address - Country:US
Practice Address - Phone:304-768-8500
Practice Address - Fax:304-768-8530
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2241207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810016359Medicaid