Provider Demographics
NPI:1023058757
Name:ANDERSON, BRADLEY TODD (DO)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:TODD
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28622 E 141ST ST S
Mailing Address - Street 2:PO BOX 1030
Mailing Address - City:COWETA
Mailing Address - State:OK
Mailing Address - Zip Code:74429-7515
Mailing Address - Country:US
Mailing Address - Phone:918-486-7425
Mailing Address - Fax:918-279-6884
Practice Address - Street 1:28622 E 141ST ST S
Practice Address - Street 2:
Practice Address - City:COWETA
Practice Address - State:OK
Practice Address - Zip Code:74429-7515
Practice Address - Country:US
Practice Address - Phone:918-486-7425
Practice Address - Fax:918-279-6884
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3893207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100126410AMedicaid
OK$$$$$$$$$-004OtherBLUE CROSS-BIXBY
OK$$$$$$$$$-002OtherBLUE CROSS-CLAREMORE
OK$$$$$$$$$-003OtherBLUE CROSS-OWASSO
OK24341500Medicare PIN
OKI03745Medicare UPIN