Provider Demographics
NPI:1841389053
Name:BRADLEY, BETTY B (MD)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:B
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 843145
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-3145
Mailing Address - Country:US
Mailing Address - Phone:910-974-7555
Mailing Address - Fax:910-974-4555
Practice Address - Street 1:210 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CANDOR
Practice Address - State:NC
Practice Address - Zip Code:27229-8088
Practice Address - Country:US
Practice Address - Phone:910-974-7555
Practice Address - Fax:910-974-4555
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC24636207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCF462AMedicare PIN