Provider Demographics
NPI:1750325338
Name:YOUNG, BRADLEY ROCKWELL
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:ROCKWELL
Last Name:YOUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16112 6TH ST E
Mailing Address - Street 2:
Mailing Address - City:REDINGTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33708-1618
Mailing Address - Country:US
Mailing Address - Phone:727-544-3330
Mailing Address - Fax:727-544-3221
Practice Address - Street 1:6231 66TH ST
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-5025
Practice Address - Country:US
Practice Address - Phone:727-544-3330
Practice Address - Fax:727-544-3221
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT17516174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY74778AMedicare ID - Type UnspecifiedMEDICARE