Provider Demographics
NPI:1922362722
Name:BRADLEY, JEREMY GILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:GILLIAM
Last Name:BRADLEY
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 1:77 NEALY AVE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23665
Mailing Address - Country:US
Mailing Address - Phone:615-337-5327
Mailing Address - Fax:757-764-1068
Practice Address - Street 1:633D MEDICAL GROUP
Practice Address - Street 2:77 NEALY AVENUE
Practice Address - City:JOINT BASE LANGELY-EUSITS
Practice Address - State:VA
Practice Address - Zip Code:23665-2040
Practice Address - Country:US
Practice Address - Phone:757-225-7630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101258260208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program