Provider Demographics
NPI:1700035235
Name:HERRICK, BRADLEY DELMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DELMAR
Last Name:HERRICK
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 1:15366 11TH ST
Mailing Address - Street 2:SUITE K
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-3726
Mailing Address - Country:US
Mailing Address - Phone:760-245-6465
Mailing Address - Fax:760-245-1132
Practice Address - Street 1:15366 11TH ST
Practice Address - Street 2:SUITE K
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3726
Practice Address - Country:US
Practice Address - Phone:760-245-6465
Practice Address - Fax:760-245-1132
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-09
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55805174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH83629Medicare UPIN