Provider Demographics
NPI:1952380255
Name:OLDS, BRADLEY S (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:S
Last Name:OLDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:110 EXECUTIVE PARK
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4201
Mailing Address - Country:US
Mailing Address - Phone:502-896-1881
Mailing Address - Fax:502-895-4586
Practice Address - Street 1:4001 DUTCHMANS LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4714
Practice Address - Country:US
Practice Address - Phone:502-893-1084
Practice Address - Fax:502-894-1324
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38168207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000057464OtherANTHEM ID#
KY64047046Medicaid
KY50006762OtherPASSPORT ID#
KY64047046Medicaid
KY0048644Medicare ID - Type UnspecifiedMEDICARE PROV ID#