Provider Demographics
NPI:1952315996
Name:FRIESEN, BRADLEY T (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:T
Last Name:FRIESEN
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 1:52 TIMBERLANE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7296
Mailing Address - Country:US
Mailing Address - Phone:802-658-2320
Mailing Address - Fax:802-863-6933
Practice Address - Street 1:52 TIMBERLANE
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7296
Practice Address - Country:US
Practice Address - Phone:802-658-2320
Practice Address - Fax:802-863-6933
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420010235208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT260145OtherMVP
VT58106OtherBLUE CROSS BLUE SHEILD
VT1007927Medicaid