Provider Demographics
NPI:1881167963
Name:ALLIS, BRADLEY JAMES (IDC)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JAMES
Last Name:ALLIS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10229 BORDELON ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3206
Mailing Address - Country:US
Mailing Address - Phone:209-401-0915
Mailing Address - Fax:
Practice Address - Street 1:10229 BORDELON ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92124-3206
Practice Address - Country:US
Practice Address - Phone:209-401-0915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-10
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman