Provider Demographics
NPI:1780047969
Name:BRADSHAW, CRYSTAL-DAWN (DPM)
Entity type:Individual
Prefix:
First Name:CRYSTAL-DAWN
Middle Name:
Last Name:BRADSHAW
Suffix:
Gender:F
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:PO BOX 844572
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-4572
Mailing Address - Country:US
Mailing Address - Phone:301-933-7133
Mailing Address - Fax:
Practice Address - Street 1:10 MEDICAL PARK STE 203
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6389
Practice Address - Country:US
Practice Address - Phone:304-243-8360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10499213E00000X
NC733213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist