Provider Demographics
NPI:1457631350
Name:BRADLEY, GARY (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:BRADLEY
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 1:2854 SE FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-5738
Mailing Address - Country:US
Mailing Address - Phone:772-223-0953
Mailing Address - Fax:772-223-0987
Practice Address - Street 1:2854 SE FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994
Practice Address - Country:US
Practice Address - Phone:772-223-0953
Practice Address - Fax:772-223-0987
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12651208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015514500Medicaid
FL015514500Medicaid