Healthcare Provider Details

I. General information

NPI: 1164656542
Provider Name (Legal Business Name): BRADLEY GLEN DEMPSEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2009
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 LAKEVIEW AVE
PUEBLO CO
81004-3597
US

IV. Provider business mailing address

902 LAKEVIEW AVE
PUEBLO CO
81004-3597
US

V. Phone/Fax

Practice location:
  • Phone: 719-557-5855
  • Fax: 719-557-5097
Mailing address:
  • Phone: 719-557-5855
  • Fax: 719-557-5097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6206
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0052763
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: