Provider Demographics
NPI:1801026893
Name:DAVIS, BRADLEY CARL (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:CARL
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:2125 CRYSTAL GROVE DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-6875
Mailing Address - Country:US
Mailing Address - Phone:863-688-2334
Mailing Address - Fax:863-577-1160
Practice Address - Street 1:1305 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4542
Practice Address - Country:US
Practice Address - Phone:863-688-2334
Practice Address - Fax:863-577-1160
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ504392085R0202X, 2085R0204X
FLME1467992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ018841Medicaid
AZ018841Medicaid