Provider Demographics
NPI:1932179306
Name:BRADWAY, LEON F III (PHYSICIAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:F
Last Name:BRADWAY
Suffix:III
Gender:M
Credentials:PHYSICIAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4006 SUNNY MEADOW BROOK CT
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845
Mailing Address - Country:UM
Mailing Address - Phone:410-271-7971
Mailing Address - Fax:
Practice Address - Street 1:2705 OSLER BLVD
Practice Address - Street 2:2011 E. VILLA MARIA RD #A
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2518
Practice Address - Country:UM
Practice Address - Phone:979-776-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-006327225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN