Provider Demographics
NPI:1841741899
Name:BRADSHAW, CURTIS
Entity Type:Individual
Prefix:
First Name:CURTIS
Middle Name:
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 1:1341 W HILL AVE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-5235
Mailing Address - Country:US
Mailing Address - Phone:229-249-7730
Mailing Address - Fax:
Practice Address - Street 1:107 WILLOW RIDGE CIR
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31757-2834
Practice Address - Country:US
Practice Address - Phone:229-516-2496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051187353171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor