Provider Demographics
NPI:1790076222
Name:BRADLEY, ADAM DEREK (DO)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:DEREK
Last Name:BRADLEY
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 1:802 S JACKSON AVE STE 505
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74127-9060
Mailing Address - Country:US
Mailing Address - Phone:918-747-5322
Mailing Address - Fax:918-746-7604
Practice Address - Street 1:802 S JACKSON AVE
Practice Address - Street 2:#505
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9015
Practice Address - Country:US
Practice Address - Phone:918-747-5322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-02
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5188208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200449100AMedicaid