Provider Demographics
NPI:1982638110
Name:WOMACK, BRADLEY GERALD (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:GERALD
Last Name:WOMACK
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 3294
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803
Mailing Address - Country:US
Mailing Address - Phone:662-377-4394
Mailing Address - Fax:622-377-7045
Practice Address - Street 1:830 SOUTH GLOSTER STREET
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801
Practice Address - Country:US
Practice Address - Phone:662-377-4394
Practice Address - Fax:662-377-7045
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17576207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126773Medicaid
H72233Medicare UPIN