Provider Demographics
NPI:1245682947
Name:JOSHUA BRADFORD
Entity type:Organization
Organization Name:JOSHUA BRADFORD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-720-8713
Mailing Address - Street 1:123 POPLAR POINT ESTS
Mailing Address - Street 2:
Mailing Address - City:POCA
Mailing Address - State:WV
Mailing Address - Zip Code:25159-8915
Mailing Address - Country:US
Mailing Address - Phone:304-720-8713
Mailing Address - Fax:
Practice Address - Street 1:123 POPLAR POINT ESTS
Practice Address - Street 2:
Practice Address - City:POCA
Practice Address - State:WV
Practice Address - Zip Code:25159-8915
Practice Address - Country:US
Practice Address - Phone:304-720-8713
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2241207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty