Provider Demographics
NPI:1295835007
Name:BRADLEY, DIANA FAISON (MD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:FAISON
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:BRADLEY
Other - Last Name:DARTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:19 NIL GIRI DR
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28803-9406
Mailing Address - Country:US
Mailing Address - Phone:828-298-3479
Mailing Address - Fax:
Practice Address - Street 1:136 CHARLOTTE HWY
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-9673
Practice Address - Country:US
Practice Address - Phone:828-296-0880
Practice Address - Fax:828-296-0855
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9601192207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891134HMedicaid
NC2253011BMedicare PIN
NC891134HMedicaid