Provider Demographics
NPI:1801110101
Name:BRADBURY, NICHOLAS COREN (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:COREN
Last Name:BRADBURY
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 2698
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58502-2698
Mailing Address - Country:US
Mailing Address - Phone:701-530-7500
Mailing Address - Fax:701-530-7484
Practice Address - Street 1:310 N 10TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4516
Practice Address - Country:US
Practice Address - Phone:701-530-7500
Practice Address - Fax:701-530-7484
Is Sole Proprietor?:No
Enumeration Date:2010-03-16
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT1932262085R0202X
UT8614430-12052085R0204X
ND133032085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology