Provider Demographics
NPI:1821089624
Name:WHITAKER, BRADLEY (DPM, FACFAS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:DPM, FACFAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2163 W ORANGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-3118
Mailing Address - Country:US
Mailing Address - Phone:520-575-0800
Mailing Address - Fax:520-575-0093
Practice Address - Street 1:2163 W ORANGE GROVE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-3118
Practice Address - Country:US
Practice Address - Phone:520-575-0800
Practice Address - Fax:520-575-0093
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0446213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ337627Medicaid
AZ5507194OtherAETNA
AZ6287561009OtherCIGNA
AZ1Z3482OtherHEALTH NET
AZ480030868OtherRAILROAD MEDICARE
AZAZ0191940OtherBLUE CROSS BLUE SHIELD
AZ337627Medicaid
AZ6287561009OtherCIGNA