Provider Demographics
NPI:1295797074
Name:BRADFORD, SUSAN ELLEN (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ELLEN
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 PATRIOTS POINTE DR
Mailing Address - Street 2:
Mailing Address - City:HLLSBOROUGH
Mailing Address - State:NC
Mailing Address - Zip Code:27278-9029
Mailing Address - Country:US
Mailing Address - Phone:919-732-4604
Mailing Address - Fax:
Practice Address - Street 1:514 PATRIOTS POINTE DR
Practice Address - Street 2:
Practice Address - City:HILLSBOROUGH
Practice Address - State:NC
Practice Address - Zip Code:27278-9029
Practice Address - Country:US
Practice Address - Phone:919-732-4604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24743207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E90649Medicare UPIN