Provider Demographics
NPI:1952394314
Name:FENSTER, BRADLEY D (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:D
Last Name:FENSTER
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 1:610 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3702
Mailing Address - Country:US
Mailing Address - Phone:570-288-5441
Mailing Address - Fax:570-288-5842
Practice Address - Street 1:610 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-3702
Practice Address - Country:US
Practice Address - Phone:570-283-5806
Practice Address - Fax:570-283-5807
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD073510L207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA069319L3FOtherGROUP MEMBER PTAN
H82793Medicare UPIN