Provider Demographics
NPI:1699185256
Name:DEKORTE, BRADLEY (DO)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:DEKORTE
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 1:2620 E BARNETT RD STE H
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8383
Mailing Address - Country:US
Mailing Address - Phone:541-789-2559
Mailing Address - Fax:
Practice Address - Street 1:555 BLACK OAK DR STE 300B
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8491
Practice Address - Country:US
Practice Address - Phone:541-789-8100
Practice Address - Fax:541-789-8101
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOL60476473207Q00000X
WAOP60576320207Q00000X
ORDO181937207Q00000X, 207QS1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2035866Medicaid