Provider Demographics
NPI:1891750568
Name:FENTON, BRADFORD W (MD)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:W
Last Name:FENTON
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 1:9500 INDEPENDENCE DRIVE
Mailing Address - Street 2:SUITE 900
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507
Mailing Address - Country:US
Mailing Address - Phone:907-522-1341
Mailing Address - Fax:907-522-1343
Practice Address - Street 1:9500 INDEPENDENCE DR STE 900
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-4686
Practice Address - Country:US
Practice Address - Phone:907-522-1341
Practice Address - Fax:907-522-1343
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01076617A207V00000X
OH35-086531207V00000X
AK102803207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2588043Medicaid
OH4164681OtherMEDICARE ID
OH4164682OtherMEDICARE ID
OH732092Medicaid
AK1639861Medicaid
OH732092Medicaid
AK1639861Medicaid