Provider Demographics
NPI:1780719823
Name:WHALEY, BRADLEY DALE (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DALE
Last Name:WHALEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1190
Mailing Address - Street 2:
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-1190
Mailing Address - Country:US
Mailing Address - Phone:831-462-7730
Mailing Address - Fax:831-462-7593
Practice Address - Street 1:1555 SOQUEL DR
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1705
Practice Address - Country:US
Practice Address - Phone:831-462-7730
Practice Address - Fax:831-462-7593
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG85157207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG99894Medicare UPIN
CACD234ZMedicare PIN