Provider Demographics
NPI:1952333072
Name:BRADSHAW, DOUGLAS MARK (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:MARK
Last Name:BRADSHAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1733 ERICKSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22801
Mailing Address - Country:US
Mailing Address - Phone:540-433-1530
Mailing Address - Fax:540-433-3941
Practice Address - Street 1:1733 ERICKSON AVENUE
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22801
Practice Address - Country:US
Practice Address - Phone:540-433-1530
Practice Address - Fax:540-433-3941
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101035633207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
215233OtherMAMSI
279087OtherANTHEM
VA5699266Medicaid
001258OtherCIGNA
144274OtherSOUTHERN HEALTH
2115954289202OtherBEECH STREET
2115954289202OtherBEECH STREET
279087OtherANTHEM