Provider Demographics
NPI:1841235173
Name:BRADSHAW, ROGER B
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:B
Last Name:BRADSHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 WINTERSAGE CIR UNIT A
Mailing Address - Street 2:
Mailing Address - City:TALENT
Mailing Address - State:OR
Mailing Address - Zip Code:97540-9566
Mailing Address - Country:US
Mailing Address - Phone:541-482-3126
Mailing Address - Fax:541-482-0593
Practice Address - Street 1:223 WINTERSAGE CIR UNIT A
Practice Address - Street 2:
Practice Address - City:TALENT
Practice Address - State:OR
Practice Address - Zip Code:97540-9515
Practice Address - Country:US
Practice Address - Phone:541-482-3126
Practice Address - Fax:541-482-0593
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21922251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR230041Medicaid
OR230041Medicaid
ORR119645Medicare PIN