Provider Demographics
NPI:1336191915
Name:SMITH, BRADLEY W (DO)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:W
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 BRIARGATE TER
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1743
Mailing Address - Country:US
Mailing Address - Phone:719-546-6300
Mailing Address - Fax:719-546-6111
Practice Address - Street 1:44 BRIARGATE TER
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1743
Practice Address - Country:US
Practice Address - Phone:719-546-6300
Practice Address - Fax:719-546-6111
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO42143207QS1201X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000146529Medicaid
CO21159335Medicaid
CO23179767Medicaid
COCOA108202Medicare PIN