Provider Demographics
NPI:1770634966
Name:PAETZ, BRADLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:PAETZ
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 1:2809 DENNY AVE
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39581-5301
Mailing Address - Country:US
Mailing Address - Phone:228-809-5510
Mailing Address - Fax:228-809-5519
Practice Address - Street 1:2809 DENNY AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-5301
Practice Address - Country:US
Practice Address - Phone:228-809-5510
Practice Address - Fax:228-809-5519
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16398208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
110191461OtherMEDICARE RAILROAD
009917135OtherALABAMA MEDICAID AT SRH
MS00121267Medicaid
MS110001225OtherMEDICARE
646000515EOtherBLUE CROSS OF MS
MS110001225OtherMEDICARE