Healthcare Provider Details

I. General information

NPI: 1821089624
Provider Name (Legal Business Name): BRADLEY WHITAKER DPM., FACFAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2163 W ORANGE GROVE RD
TUCSON AZ
85741-3118
US

IV. Provider business mailing address

2163 W ORANGE GROVE RD
TUCSON AZ
85741-3118
US

V. Phone/Fax

Practice location:
  • Phone: 520-575-0800
  • Fax: 520-575-0093
Mailing address:
  • Phone: 520-575-0800
  • Fax: 520-575-0093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0446
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: