Healthcare Provider Details

I. General information

NPI: 1669414553
Provider Name (Legal Business Name): EARL B BRADLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 HIGHWAY ONE
LEWES DE
19958-9641
US

IV. Provider business mailing address

1503 HIGHWAY ONE
LEWES DE
19958-9641
US

V. Phone/Fax

Practice location:
  • Phone: 302-645-0222
  • Fax: 302-645-0899
Mailing address:
  • Phone: 302-645-0222
  • Fax: 302-645-0899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC1-1004285
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: