Healthcare Provider Details

I. General information

NPI: 1952862765
Provider Name (Legal Business Name): BRADLEY GONIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 S ALMA SCHOOL RD STE 130
MESA AZ
85210-3088
US

IV. Provider business mailing address

1830 S ALMA SCHOOL RD STE 130
MESA AZ
85210-3088
US

V. Phone/Fax

Practice location:
  • Phone: 480-565-8590
  • Fax: 480-856-0285
Mailing address:
  • Phone: 480-565-8590
  • Fax: 480-856-0285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number67841
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: