Provider Demographics
NPI:1265437057
Name:BOMBA, BRADFORD J JR (MD)
Entity type:Individual
Prefix:
First Name:BRADFORD
Middle Name:J
Last Name:BOMBA
Suffix:JR
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 1:550 S LANDMARK AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3239
Mailing Address - Country:US
Mailing Address - Phone:812-331-3409
Mailing Address - Fax:812-331-3656
Practice Address - Street 1:550 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3239
Practice Address - Country:US
Practice Address - Phone:812-331-3409
Practice Address - Fax:812-331-3656
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10137706A208M00000X
IN01037706A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100184700Medicaid
IN100184700Medicaid
INM400021619Medicare PIN
IN549210CMedicare ID - Type Unspecified