Provider Demographics
NPI:1265541379
Name:BRADLEY, RICHARD C (DPM)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
Last Name:BRADLEY
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 1:188 FRIES MILL RD STE D2
Mailing Address - Street 2:
Mailing Address - City:TURNERSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-2015
Mailing Address - Country:US
Mailing Address - Phone:856-629-7300
Mailing Address - Fax:856-629-8729
Practice Address - Street 1:188 FRIES MILL RD STE D2
Practice Address - Street 2:
Practice Address - City:TURNERSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08012
Practice Address - Country:US
Practice Address - Phone:856-629-7300
Practice Address - Fax:856-629-8729
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00213000213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
0114550000OtherKEYSTONE AND AMERIHEALTH
NJ5172101Medicaid
PA601173OtherMEDICARE-TYPE UNSPECIFIED
NJ726253R63Medicare PIN
PA601173OtherMEDICARE-TYPE UNSPECIFIED
0114550000OtherKEYSTONE AND AMERIHEALTH
NJ5172101Medicaid