Provider Demographics
NPI:1013163542
Name:BRADDOCK, ADAM (MD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:BRADDOCK
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 1:7910 FROST ST
Mailing Address - Street 2:SUITE 350
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2771
Mailing Address - Country:US
Mailing Address - Phone:858-496-4800
Mailing Address - Fax:
Practice Address - Street 1:7910 FROST ST
Practice Address - Street 2:SUITE 350
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2771
Practice Address - Country:US
Practice Address - Phone:858-496-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1146712080P0006X, 208000000X
IL125-053642208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics