Provider Demographics
NPI:1700821147
Name:TALLEY, BRAD DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:DOUGLAS
Last Name:TALLEY
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 1:3599 UNIVERSITY BLVD. S.
Mailing Address - Street 2:BLDG. 300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-0000
Mailing Address - Country:US
Mailing Address - Phone:904-399-5550
Mailing Address - Fax:904-346-4334
Practice Address - Street 1:3599 UNIVERSITY BLVD. S.
Practice Address - Street 2:BLDG. 300
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216
Practice Address - Country:US
Practice Address - Phone:904-399-5550
Practice Address - Fax:904-346-4334
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1037402085R0202X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBW001ZMedicare PIN