Provider Demographics
NPI:1205810512
Name:WHITE, BRAD C (MD)
Entity type:Individual
Prefix:DR
First Name:BRAD
Middle Name:C
Last Name:WHITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:12855 N 40 DR
Mailing Address - Street 2:SUITE 375
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8635
Mailing Address - Country:US
Mailing Address - Phone:314-567-6071
Mailing Address - Fax:314-567-7961
Practice Address - Street 1:12855 N 40 DR
Practice Address - Street 2:SUITE 375
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8635
Practice Address - Country:US
Practice Address - Phone:314-567-6071
Practice Address - Fax:314-567-7961
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-097383208800000X
MO114377208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203832209Medicaid
ILL63769Medicare PIN