Provider Demographics
NPI:1760913057
Name:BRADLEY, MELANIE LORETTA (DO)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:LORETTA
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:LORETTA
Other - Last Name:BURNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40 ROYAL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-0537
Mailing Address - Country:US
Mailing Address - Phone:904-208-8724
Mailing Address - Fax:
Practice Address - Street 1:101 MARKETSIDE AVE STE 405
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-1542
Practice Address - Country:US
Practice Address - Phone:904-223-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-27
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS16693208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty