Provider Demographics
NPI:1356408116
Name:BRADLEY, MARK WINTER (LMT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WINTER
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:756 PREAKNESS DR
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-7310
Mailing Address - Country:US
Mailing Address - Phone:321-749-1924
Mailing Address - Fax:
Practice Address - Street 1:756 PREAKNESS DR
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-7310
Practice Address - Country:US
Practice Address - Phone:321-749-1924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 4120174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist