Provider Demographics
NPI:1720488497
Name:HAVELKA, BRADLEY (EDS)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:HAVELKA
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6477 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-4109
Mailing Address - Country:US
Mailing Address - Phone:440-974-5332
Mailing Address - Fax:
Practice Address - Street 1:6477 CENTER ST
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4109
Practice Address - Country:US
Practice Address - Phone:440-974-5332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3175620174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist