Healthcare Provider Details

I. General information

NPI: 1194729582
Provider Name (Legal Business Name): BRADLEY J. G. LARSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 12/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 CLINIC AVE STE 101
CARROLLTON GA
30117-4413
US

IV. Provider business mailing address

531 ROSELANE ST NW STE 710
MARIETTA GA
30060-6975
US

V. Phone/Fax

Practice location:
  • Phone: 770-333-2220
  • Fax: 678-581-7180
Mailing address:
  • Phone: 678-331-3297
  • Fax: 678-581-7187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number054449
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: