Provider Demographics
NPI:1932279726
Name:SMITH, BRADLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:SMITH
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 1:1106 S PACIFIC COAST HWY
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-4902
Mailing Address - Country:US
Mailing Address - Phone:310-316-1661
Mailing Address - Fax:
Practice Address - Street 1:1106 S PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-4902
Practice Address - Country:US
Practice Address - Phone:310-316-1661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG066535207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ32051ZMedicaid
CAZZZ32051ZOtherBLUE SHIELD
CAZZZ32051ZOtherBLUE SHIELD
CAE36033Medicare UPIN