Provider Demographics
NPI:1649258047
Name:FROST, BRADLEY L (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:L
Last Name:FROST
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:PO BOX 1528
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31040-1528
Mailing Address - Country:US
Mailing Address - Phone:478-272-1366
Mailing Address - Fax:478-275-2322
Practice Address - Street 1:104 FAIRVIEW PARK DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021
Practice Address - Country:US
Practice Address - Phone:478-272-1366
Practice Address - Fax:478-275-2322
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052723207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA278071734AMedicaid
GA2501178OtherUNITED HEALTHCARE
GA7938678OtherAETNA
GA5590639OtherFIRST HEALTH
GA52168676-001OtherBCBS
GA5590639OtherFIRST HEALTH
GA2501178OtherUNITED HEALTHCARE