MEDICARE: DR. LARRY EDWIN BRADLEY D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	H6067	TX

General Provider Information

NPI Number	:	1962711036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY EDWIN BRADLEY D.O.

Provider Business Mailing Address
First Line	:	7016 RIVERPORT RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-9311
Country	:	US
Telephone Number	:	817-738-4288
Fax Number	:

Provider Business Practice Location Address
First Line	:	7016 RIVERPORT RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-9311
Country	:	US
Telephone Number	:	817-738-4288
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2010
Last Update Date	:	10/06/2010

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