Provider Demographics
NPI:1851483291
Name:BRADLEY, JEREMY L (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:L
Last Name:BRADLEY
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 1:3122 COMMONWEALTH CT
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-2258
Mailing Address - Country:US
Mailing Address - Phone:270-684-7711
Mailing Address - Fax:270-684-7753
Practice Address - Street 1:3122 COMMONWEALTH CT
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-2258
Practice Address - Country:US
Practice Address - Phone:270-684-7711
Practice Address - Fax:270-684-7753
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31984207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64319841Medicaid
KY000000075315OtherBC/BS
KY64319841Medicaid
KY1826501Medicare ID - Type Unspecified