Provider Demographics
NPI:1104925247
Name:PICCOLO, BRADLEY (PT)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:PICCOLO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:SUITE #141; ATTN: TERRI
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-936-5800
Mailing Address - Fax:405-936-5211
Practice Address - Street 1:4300 W MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8304
Practice Address - Country:US
Practice Address - Phone:405-341-7356
Practice Address - Fax:405-341-3795
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2548225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2548OtherPT LICENSE
OK2548OtherPT LICENSE