Provider Demographics
NPI:1649504366
Name:BRADLEY SMITH MD PC
Entity type:Organization
Organization Name:BRADLEY SMITH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-571-5071
Mailing Address - Street 1:PO BOX 576900
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-6900
Mailing Address - Country:US
Mailing Address - Phone:209-451-2377
Mailing Address - Fax:209-433-0441
Practice Address - Street 1:1329 SPANOS CT STE C1
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2806
Practice Address - Country:US
Practice Address - Phone:209-451-2377
Practice Address - Fax:209-433-0441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-28
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79816207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G75471Medicare UPIN
CACW978AMedicare PIN