Provider Demographics
NPI:1750309522
Name:ALLEN, BRADLEY S (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:S
Last Name:ALLEN
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 1:10398 W SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-3613
Mailing Address - Country:US
Mailing Address - Phone:310-276-0004
Mailing Address - Fax:310-273-0818
Practice Address - Street 1:10398 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90077-3613
Practice Address - Country:US
Practice Address - Phone:310-276-0004
Practice Address - Fax:310-273-0818
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7300208G00000X
CAG51838208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F6681OtherBCBS
TX157995501Medicaid
TXP00017417OtherRAILROAD MEDICARE
TXA93116Medicare UPIN
TX157995501Medicaid