Healthcare Provider Details

I. General information

NPI: 1013163542
Provider Name (Legal Business Name): ADAM LAWRENCE BRADDOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2008
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910 FROST ST SUITE 350
SAN DIEGO CA
92123-2771
US

IV. Provider business mailing address

7910 FROST ST SUITE 350
SAN DIEGO CA
92123-2771
US

V. Phone/Fax

Practice location:
  • Phone: 858-496-4800
  • Fax:
Mailing address:
  • Phone: 858-496-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125-053642
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License NumberA114671
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA114671
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: