Healthcare Provider Details

I. General information

NPI: 1174885859
Provider Name (Legal Business Name): KURTIS WAYNE BRADLEY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 05/18/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E DUNLAP AVE
PHOENIX AZ
85020-2825
US

IV. Provider business mailing address

9225 N 3RD ST SUITE 300
PHOENIX AZ
85020-2439
US

V. Phone/Fax

Practice location:
  • Phone: 602-445-0751
  • Fax: 602-424-8128
Mailing address:
  • Phone: 602-445-0751
  • Fax: 602-424-8128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number006622
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number006622
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: