Provider Demographics
NPI:1760401657
Name:WILCOX, BRADLEY E (DO)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:E
Last Name:WILCOX
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-643-7900
Mailing Address - Fax:515-643-7901
Practice Address - Street 1:411 LAUREL ST STE A120
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-3027
Practice Address - Country:US
Practice Address - Phone:515-643-7900
Practice Address - Fax:515-643-7901
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49087207RP1001X
MN102479207RP1001X
IADO-03941207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN841652000Medicaid
MN290000520Medicare ID - Type Unspecified
MNP00342144Medicare ID - Type UnspecifiedRAILROAD
MN841652000Medicaid