Provider Demographics
NPI:1861447039
Name:MILLER, BRADLEY K (DO)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:K
Last Name:MILLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 244
Mailing Address - Street 2:
Mailing Address - City:NEW MARTINSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26155-0244
Mailing Address - Country:US
Mailing Address - Phone:304-455-8010
Mailing Address - Fax:304-455-8075
Practice Address - Street 1:150 PADUCAH DR
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155-2710
Practice Address - Country:US
Practice Address - Phone:304-455-8190
Practice Address - Fax:304-455-8131
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1051207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0042185000Medicaid
OH0751664Medicaid
E74765Medicare UPIN
WV0042185000Medicaid