Provider Demographics
NPI:1265429310
Name:JANN, BRADLEY GLENN (DPM)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:GLENN
Last Name:JANN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751347
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94975-1347
Mailing Address - Country:US
Mailing Address - Phone:415-461-5995
Mailing Address - Fax:707-545-1783
Practice Address - Street 1:100 THORNDALE DR
Practice Address - Street 2:MEDICAL CLINIC
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-4501
Practice Address - Country:US
Practice Address - Phone:415-461-5995
Practice Address - Fax:415-461-5995
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3865213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E38650Medicaid
CA000E38650Medicare ID - Type Unspecified
CA000E38650Medicaid