Provider Demographics
NPI:1972559714
Name:BRADBURN, ERIC W (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:W
Last Name:BRADBURN
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:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7840
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:475 SHOPPERS DR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-1380
Practice Address - Country:US
Practice Address - Phone:859-744-5111
Practice Address - Fax:859-744-1177
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35962208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6400OtherMEDICARE GROUP NUMBER
KY64068257Medicaid
KY64068257Medicaid
KY6400OtherMEDICARE GROUP NUMBER