Provider Demographics
NPI:1700178092
Name:GRADISEK, BRIAN P (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:P
Last Name:GRADISEK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 28TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-1096
Mailing Address - Country:US
Mailing Address - Phone:303-449-2000
Mailing Address - Fax:303-449-9475
Practice Address - Street 1:1400 28TH ST STE 2
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1096
Practice Address - Country:US
Practice Address - Phone:303-449-2000
Practice Address - Fax:303-449-9475
Is Sole Proprietor?:No
Enumeration Date:2011-05-05
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005597213E00000X, 213ES0103X
CO0000766213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005597Medicaid
ILF400161570Medicare PIN