Healthcare Provider Details

I. General information

NPI: 1134126220
Provider Name (Legal Business Name): BRADLEY ROBERT PRESTIDGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5930 CORNERSTONE CT W
SAN DIEGO CA
92121-3741
US

IV. Provider business mailing address

5930 CORNERSTONE CT W
SAN DIEGO CA
92121-3741
US

V. Phone/Fax

Practice location:
  • Phone: 619-502-9084
  • Fax:
Mailing address:
  • Phone: 612-502-9084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number70262
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberH8803
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number036168260
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: