Provider Demographics
NPI:1245273382
Name:BRADLEY, WILLIAM DANIEL (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DANIEL
Last Name:BRADLEY
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 1:2960 E. ST. LUKES ST.
Mailing Address - Street 2:STE. 200
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6011
Mailing Address - Country:US
Mailing Address - Phone:208-992-5212
Mailing Address - Fax:208-992-5452
Practice Address - Street 1:2960 E. ST. LUKES ST.
Practice Address - Street 2:STE. 200
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6011
Practice Address - Country:US
Practice Address - Phone:208-992-5212
Practice Address - Fax:208-992-5452
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0043207XS0117X
IDM-13237207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0405045-01Medicaid
TXH25888Medicare UPIN
TX8248K3Medicare PIN