Healthcare Provider Details

I. General information

NPI: 1942230925
Provider Name (Legal Business Name): BRADLEY DON RASMUSSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 E AGAVE RD SUITE 148
PHOENIX AZ
85044-0619
US

IV. Provider business mailing address

4425 E AGAVE RD SUITE 148
PHOENIX AZ
85044-0619
US

V. Phone/Fax

Practice location:
  • Phone: 480-704-7546
  • Fax: 480-704-7549
Mailing address:
  • Phone: 480-704-7546
  • Fax: 480-704-7549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number5663814-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number27555
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: