Provider Demographics
NPI:1750355947
Name:COLEGATE, BRADFORD (MD)
Entity type:Individual
Prefix:
First Name:BRADFORD
Middle Name:
Last Name:COLEGATE
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 583
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-0583
Mailing Address - Country:US
Mailing Address - Phone:614-284-0608
Mailing Address - Fax:
Practice Address - Street 1:1505 CLARK ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-9232
Practice Address - Country:US
Practice Address - Phone:614-284-0608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-043797207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0472608Medicaid
OHCO0848771Medicare ID - Type Unspecified
OH0472608Medicaid