Provider Demographics
NPI:1184694663
Name:LAWRENCE, BRADLEY T (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:T
Last Name:LAWRENCE
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 1:710 W BELL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-3507
Mailing Address - Country:US
Mailing Address - Phone:602-588-3800
Mailing Address - Fax:602-588-3671
Practice Address - Street 1:710 W BELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-3507
Practice Address - Country:US
Practice Address - Phone:602-588-3800
Practice Address - Fax:602-588-3671
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ208224Medicaid
AZ208224Medicaid
AZ74883Medicare ID - Type Unspecified