Provider Demographics
NPI:1821095654
Name:BRADFORD, WESLEY G (MD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:G
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5122 OCONTO AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-3733
Mailing Address - Country:US
Mailing Address - Phone:310-541-6686
Mailing Address - Fax:
Practice Address - Street 1:5122 OCONTO AVE
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-3733
Practice Address - Country:US
Practice Address - Phone:310-541-6686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG-30342207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA-91279Medicare UPIN
CAG30342AMedicare ID - Type Unspecified