Provider Demographics
NPI:1760574123
Name:BRADSHAW, TONDA DALE (DO)
Entity Type:Individual
Prefix:
First Name:TONDA
Middle Name:DALE
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35237 YUCAIPA BLVD
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-4340
Mailing Address - Country:US
Mailing Address - Phone:909-790-6200
Mailing Address - Fax:909-790-6220
Practice Address - Street 1:35237 YUCAIPA BLVD
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-4340
Practice Address - Country:US
Practice Address - Phone:909-790-6200
Practice Address - Fax:909-790-6220
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6282207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX62821Medicaid
CAJ301879OtherINLAND EMPIRE HEALTH PLAN
CAJ301879OtherINLAND EMPIRE HEALTH PLAN
CA00AX62821Medicaid