Provider Demographics
NPI:1881071041
Name:BRADLEY, SEAN (MD)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:BRADLEY
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 1:10310 THE GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70836-6455
Mailing Address - Country:US
Mailing Address - Phone:225-761-5200
Mailing Address - Fax:
Practice Address - Street 1:10310 THE GROVE BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70836-6455
Practice Address - Country:US
Practice Address - Phone:225-761-5200
Practice Address - Fax:225-761-5450
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-27
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10077814-1205207R00000X
390200000X
LA323284207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program