Provider Demographics
NPI:1710912951
Name:BLACK, BRADFORD T (MD)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:T
Last Name:BLACK
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 1:1508 DIVISION ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1582
Mailing Address - Country:US
Mailing Address - Phone:503-656-0836
Mailing Address - Fax:503-656-9464
Practice Address - Street 1:1508 DIVISION ST
Practice Address - Street 2:SUITE 105
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1582
Practice Address - Country:US
Practice Address - Phone:503-656-0836
Practice Address - Fax:503-656-9464
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23801207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286571Medicaid
OR286571Medicaid
ORR113319Medicare PIN