Provider Demographics
NPI:1790120731
Name:WARNER, BRAD EDWARD (DO)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:EDWARD
Last Name:WARNER
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 1:3640 NEW VISION DR STE A
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1717
Mailing Address - Country:US
Mailing Address - Phone:260-482-4440
Mailing Address - Fax:260-482-4442
Practice Address - Street 1:11109 PARKVIEW PLAZA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1701
Practice Address - Country:US
Practice Address - Phone:260-266-1000
Practice Address - Fax:260-482-4442
Is Sole Proprietor?:No
Enumeration Date:2013-05-03
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004712A207P00000X
MI5101020386390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000995809OtherANTHEM
OH0178315Medicaid
IN201338120Medicaid