Provider Demographics
NPI:1972501401
Name:BRADFORD, BRADLEY JOHN (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JOHN
Last Name:BRADFORD
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 1:285 SE 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33483-5206
Mailing Address - Country:US
Mailing Address - Phone:561-272-8991
Mailing Address - Fax:561-272-8985
Practice Address - Street 1:285 SE 5TH AVE
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33483-5206
Practice Address - Country:US
Practice Address - Phone:561-272-8991
Practice Address - Fax:561-272-8985
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80414208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10511OtherDIMENSION
FL268188901Medicaid
FL278678OtherWELLCARE
FL30114893OtherHUMANA
FL238939OtherAMERIGROUP
FL278678OtherHEALTHEASE
FL332659OtherPHC
FL3580558OtherAETNA
FL37543OtherBCBS
FL0610645OtherCIGNA
FL293270OtherAV MED
FL114893OtherHUMANA HMO
FLP3606154OtherOXFORD
FL10467OtherTOTAL HEALTH CHOICE
FL278678OtherSTAYWELL
FLFP4185OtherBEECH STREET
FL332659OtherPHC