Provider Demographics
NPI:1700824307
Name:BIBB, BRADLEY RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:RAY
Last Name:BIBB
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 1:49 HIGHWAY 62 412
Mailing Address - Street 2:
Mailing Address - City:ASH FLAT
Mailing Address - State:AR
Mailing Address - Zip Code:72513-9594
Mailing Address - Country:US
Mailing Address - Phone:870-994-7301
Mailing Address - Fax:870-994-7488
Practice Address - Street 1:49 HIGHWAY 62 412
Practice Address - Street 2:
Practice Address - City:ASH FLAT
Practice Address - State:AR
Practice Address - Zip Code:72513-9594
Practice Address - Country:US
Practice Address - Phone:870-994-7301
Practice Address - Fax:870-994-7488
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-4136207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR155872001Medicaid
AR5N123Medicare ID - Type Unspecified
AR155872001Medicaid