Provider Demographics
NPI:1750356663
Name:CONNETT, BRADLEY D (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:D
Last Name:CONNETT
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 1:1075 NICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3093
Mailing Address - Country:US
Mailing Address - Phone:573-302-3111
Mailing Address - Fax:573-302-2869
Practice Address - Street 1:1075 NICHOLS RD
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3093
Practice Address - Country:US
Practice Address - Phone:573-302-3111
Practice Address - Fax:573-302-2869
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO102732208800000X
KS0424419208800000X
KY26727208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
340017670OtherRAILROAD MEDICARE
KS100153430BMedicaid
E39238Medicare UPIN
KS100153430BMedicaid
MO4635088AMedicare PIN
KS057380COMedicare PIN