Provider Demographics
NPI:1811296551
Name:BRADLEY, DANIEL WILLIAM
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:WILLIAM
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4994 SHIFFER RD
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-9042
Mailing Address - Country:US
Mailing Address - Phone:570-688-6860
Mailing Address - Fax:
Practice Address - Street 1:4994 SHIFFER RD
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-9042
Practice Address - Country:US
Practice Address - Phone:570-688-6860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPA077942171W00000X, 171WH0202X, 171WV0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No171WH0202XOther Service ProvidersContractorHome Modifications
No171WV0202XOther Service ProvidersContractorVehicle Modifications