Healthcare Provider Details

I. General information

NPI: 1861293243
Provider Name (Legal Business Name): BRADLEY BOMAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2025
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11851 N 51ST AVE STE E130
GLENDALE AZ
85304-2843
US

IV. Provider business mailing address

11851 N 51ST AVE STE E130
GLENDALE AZ
85304-2843
US

V. Phone/Fax

Practice location:
  • Phone: 623-299-9540
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number012621
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: