Provider Demographics
NPI:1780632851
Name:BRADSHAW, CHARLES B (PHD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:B
Last Name:BRADSHAW
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 E ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2306
Mailing Address - Country:US
Mailing Address - Phone:315-464-5016
Mailing Address - Fax:315-464-7328
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:DEPARTMENT OF NEUROLOGY
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2306
Practice Address - Country:US
Practice Address - Phone:315-464-5016
Practice Address - Fax:315-464-5355
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010159103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01207905Medicaid
NY35124TMedicare PIN
NY01207905Medicaid