Healthcare Provider Details

I. General information

NPI: 1073516381
Provider Name (Legal Business Name): BRADLEY JOHN FOLKESTAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18699 N 67TH AVE STE 320
GLENDALE AZ
85308-7143
US

IV. Provider business mailing address

18699 N 67TH AVE STE 320
GLENDALE AZ
85308-7143
US

V. Phone/Fax

Practice location:
  • Phone: 623-561-7250
  • Fax: 623-561-0098
Mailing address:
  • Phone: 623-561-7250
  • Fax: 623-561-0098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number19824
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: