Provider Demographics
NPI:1013154632
Name:HARE, BRADLEY DWAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DWAYNE
Last Name:HARE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2727 PACES FERRY RD SE STE 1-1100
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-6151
Mailing Address - Country:US
Mailing Address - Phone:706-253-2430
Mailing Address - Fax:706-692-0155
Practice Address - Street 1:80 INTERSTATE SOUTH DR STE B
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143
Practice Address - Country:US
Practice Address - Phone:706-253-2430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA072683208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery