Healthcare Provider Details

I. General information

NPI: 1205196391
Provider Name (Legal Business Name): BRADLEY A ETHINGTON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2012
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 E 13TH ST STE 130
LOVELAND CO
80537-5135
US

IV. Provider business mailing address

2555 E 13TH ST STE 130
LOVELAND CO
80537-5135
US

V. Phone/Fax

Practice location:
  • Phone: 970-663-5437
  • Fax: 970-669-5762
Mailing address:
  • Phone: 970-663-5437
  • Fax: 970-669-5762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number94-07861
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: