Provider Demographics
NPI:1639270853
Name:BRADLEY, JEFFREY A (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 15TH ST NE APT 1235
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-3587
Mailing Address - Country:US
Mailing Address - Phone:864-270-7746
Mailing Address - Fax:
Practice Address - Street 1:870 CRESTMARK DR STE 203
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-2665
Practice Address - Country:US
Practice Address - Phone:470-881-8757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC150598207V00000X
GA0363452084P0802X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1295769438OtherGROUP NPI NUMBER
SC1295769438OtherGROUP NPI NUMBER
SCF84860Medicare UPIN