Provider Demographics
NPI:1912005190
Name:SEMEGON, BRADLEY G (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:G
Last Name:SEMEGON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7248 MERRILL RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-3725
Mailing Address - Country:US
Mailing Address - Phone:904-744-4461
Mailing Address - Fax:904-744-3259
Practice Address - Street 1:7248 MERRILL RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-3725
Practice Address - Country:US
Practice Address - Phone:904-744-4461
Practice Address - Fax:904-744-3259
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0004819111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT-55036Medicare UPIN