Healthcare Provider Details

I. General information

NPI: 1356342224
Provider Name (Legal Business Name): BRADLEY J BRAINARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 N WYATT DR
TUCSON AZ
85712-6115
US

IV. Provider business mailing address

PO BOX 31630
TUCSON AZ
85751-1630
US

V. Phone/Fax

Practice location:
  • Phone: 520-784-6200
  • Fax: 520-784-6109
Mailing address:
  • Phone: 520-784-6200
  • Fax: 520-784-6109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number15663
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number15663
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: