Healthcare Provider Details

I. General information

NPI: 1144255753
Provider Name (Legal Business Name): EDWARD T BRADBURY MD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 03/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 CARNATION DR SUITE 2
FREEDOM CA
95019-3132
US

IV. Provider business mailing address

PO BOX 1899
FREEDOM CA
95019-1899
US

V. Phone/Fax

Practice location:
  • Phone: 831-722-8123
  • Fax:
Mailing address:
  • Phone: 831-722-8123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA23889
License Number StateCA

VIII. Authorized Official

Name: DR. EDWARD BRADBURY
Title or Position: OWNER
Credential: M.D.
Phone: 831-722-8123