Provider Demographics
NPI:1134197924
Name:BRADSHAW, KENNETH (DPM)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BRADSHAW
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1602 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-1192
Mailing Address - Country:US
Mailing Address - Phone:660-885-8171
Mailing Address - Fax:660-890-8485
Practice Address - Street 1:1602 N 2ND ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-1192
Practice Address - Country:US
Practice Address - Phone:660-885-8171
Practice Address - Fax:660-890-8485
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000385213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT77040Medicare UPIN
MO787F756Medicare PIN