Provider Demographics
NPI:1710231303
Name:BRADBERRY, DOUGLAS WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:WAYNE
Last Name:BRADBERRY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 PARK RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2296
Mailing Address - Country:US
Mailing Address - Phone:727-581-2774
Mailing Address - Fax:727-581-3199
Practice Address - Street 1:4601 PARK RD STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-2296
Practice Address - Country:US
Practice Address - Phone:704-527-7246
Practice Address - Fax:704-527-3080
Is Sole Proprietor?:No
Enumeration Date:2012-11-03
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4405111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor