Provider Demographics
NPI:1952862765
Name:GONIK, BRADLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:GONIK
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 1:6301 S MCCLINTOCK DR STE 201
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-3394
Mailing Address - Country:US
Mailing Address - Phone:480-838-3100
Mailing Address - Fax:480-838-3902
Practice Address - Street 1:6301 S MCCLINTOCK DR STE 201
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-3394
Practice Address - Country:US
Practice Address - Phone:480-838-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ67841207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program