Provider Demographics
NPI:1891764700
Name:MUDGE, BRADLEY PIERCE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:PIERCE
Last Name:MUDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:240 NEWPORT CENTER DR
Mailing Address - Street 2:#105
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7512
Mailing Address - Country:US
Mailing Address - Phone:949-644-2450
Mailing Address - Fax:949-644-2451
Practice Address - Street 1:240 NEWPORT CENTER DRIVE
Practice Address - Street 2:SUITE 105
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7538
Practice Address - Country:US
Practice Address - Phone:949-644-2450
Practice Address - Fax:949-644-2451
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79221207N00000X, 2082S0105X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
H66771Medicare UPIN
CAWA79221CMedicare PIN