Healthcare Provider Details

I. General information

NPI: 1619104130
Provider Name (Legal Business Name): BRADLEY VERNON BENSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 WILLOW CREEK RD STE 3100
PRESCOTT AZ
86301-1614
US

IV. Provider business mailing address

PO BOX 10880
PRESCOTT AZ
86304-0880
US

V. Phone/Fax

Practice location:
  • Phone: 928-445-4818
  • Fax: 928-445-4837
Mailing address:
  • Phone: 602-406-4786
  • Fax: 916-636-4358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number005884
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: