Provider Demographics
NPI:1871658500
Name:DAIGLE, BRADLEY ALLAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:ALLAN
Last Name:DAIGLE
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:PO BOX 2738
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-2738
Mailing Address - Country:US
Mailing Address - Phone:760-934-1694
Mailing Address - Fax:
Practice Address - Street 1:473 MAJESTIC PINES DRIVE
Practice Address - Street 2:
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546-2738
Practice Address - Country:US
Practice Address - Phone:760-934-1694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG26243171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor