Provider Demographics
NPI:1922079151
Name:CASTELLANO, BRADLEY DAVID (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DAVID
Last Name:CASTELLANO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 RIVER PL
Mailing Address - Street 2:SUITE 140
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-5602
Mailing Address - Country:US
Mailing Address - Phone:770-648-5040
Mailing Address - Fax:
Practice Address - Street 1:1515 RIVER PL
Practice Address - Street 2:SUITE 140
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-5602
Practice Address - Country:US
Practice Address - Phone:770-648-5040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000569213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA116103838AMedicaid
GA65107OtherMEDICARE ID TYPE UNSPECIFIED
GA65107OtherMEDICARE ID TYPE UNSPECIFIED
T92374Medicare UPIN