Healthcare Provider Details

I. General information

NPI: 1568464436
Provider Name (Legal Business Name): HENRY LANE BRADFORD DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 TUSCALOOSA AVE
GADSDEN AL
35901-3005
US

IV. Provider business mailing address

PO BOX 97
GADSDEN AL
35902-0097
US

V. Phone/Fax

Practice location:
  • Phone: 256-492-0131
  • Fax:
Mailing address:
  • Phone: 256-492-0131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number312
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: