Healthcare Provider Details

I. General information

NPI: 1831250331
Provider Name (Legal Business Name): LORELLE E BRADLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 02/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 GEORGIA AVE NW RM 6B42
WASHINGTON DC
20060-0001
US

IV. Provider business mailing address

2041 GEORGIA AVE NW RM 6B42
WASHINGTON DC
20060-0001
US

V. Phone/Fax

Practice location:
  • Phone: 202-865-4554
  • Fax: 202-865-4558
Mailing address:
  • Phone: 202-865-4554
  • Fax: 202-865-4558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD33454
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: