Healthcare Provider Details

I. General information

NPI: 1548701089
Provider Name (Legal Business Name): BRADFORD THOMAS RILEY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2017
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

U.S. NMRTC YOKOSUKA MCAS IWAKUNI
FPO AP
96310
US

IV. Provider business mailing address

PSC 561 BOX 1877
FPO AP
96310-0019
US

V. Phone/Fax

Practice location:
  • Phone: 315-243-8649
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0102205405
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: