Provider Demographics
NPI:1710162169
Name:BRADLEY TODD
Entity Type:Organization
Organization Name:BRADLEY TODD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:P
Authorized Official - Last Name:TODD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:954-566-2580
Mailing Address - Street 1:3367 GALT OCEAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-7002
Mailing Address - Country:US
Mailing Address - Phone:954-566-2580
Mailing Address - Fax:954-566-8929
Practice Address - Street 1:3367 GALT OCEAN DRIVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-7002
Practice Address - Country:US
Practice Address - Phone:954-566-2580
Practice Address - Fax:954-566-8929
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR BRADLEY TODD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-04
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3045213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4935660001Medicare NSC