Healthcare Provider Details

I. General information

NPI: 1316107428
Provider Name (Legal Business Name): MARK BRADSHAW M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2008
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 GLENLAKE PKWY STE 420
SANDY SPRINGS GA
30328-3489
US

IV. Provider business mailing address

2 UNIVERSITY PLZ STE 204
HACKENSACK NJ
07601-6211
US

V. Phone/Fax

Practice location:
  • Phone: 551-295-8223
  • Fax:
Mailing address:
  • Phone: 404-367-3014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101286220
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25IA12524000
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number04-50270
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2025052488
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number003457
License Number StateGA
# 6
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number066574
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0102042
License Number StateMD
# 8
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME172056
License Number StateFL
# 9
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number44688
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: