Provider Demographics
NPI:1972663888
Name:BRADSHAW, KEVIN C (DPM)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:C
Last Name:BRADSHAW
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 PEABODY ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-1647
Mailing Address - Country:US
Mailing Address - Phone:202-285-1465
Mailing Address - Fax:202-635-2305
Practice Address - Street 1:519 PEABODY ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-1647
Practice Address - Country:US
Practice Address - Phone:202-285-1465
Practice Address - Fax:202-635-2305
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPO526213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
48002901OtherMEDICARE/RAILROAD PIN
DC0115995 00Medicaid
DC0115995 00Medicaid
DC745939Medicare PIN
DC48002901Medicare PIN