Provider Demographics
NPI:1205819125
Name:WEBER, BRADLEY ALAN (DO)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:ALAN
Last Name:WEBER
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 1:7964 DEEP WOODS CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-8777
Mailing Address - Country:US
Mailing Address - Phone:937-554-7385
Mailing Address - Fax:937-554-7385
Practice Address - Street 1:7901 SCHATZ POINTE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-3856
Practice Address - Country:US
Practice Address - Phone:937-439-0390
Practice Address - Fax:937-439-7370
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004205W2085R0202X
OH34-004205208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0748196Medicaid
OH4121814Medicare PIN
OH4121813Medicare PIN
OH4121817Medicare PIN
OH0748196Medicaid
OHP00964849Medicare PIN
OH4121815Medicare PIN
E51848Medicare UPIN