Healthcare Provider Details

I. General information

NPI: 1265891634
Provider Name (Legal Business Name): BRADLEY MATTHEW WHITE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 IRVIN WAY SUITE 102
DECATUR GA
30030-5405
US

IV. Provider business mailing address

1551 JANMAR RD
SNELLVILLE GA
30078-5606
US

V. Phone/Fax

Practice location:
  • Phone: 678-344-8900
  • Fax: 678-666-5201
Mailing address:
  • Phone: 678-344-8900
  • Fax: 678-666-5201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number105153
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number105153
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: