Healthcare Provider Details

I. General information

NPI: 1255427597
Provider Name (Legal Business Name): BRADLEY T DEWALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 06/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21985 277TH AVE
LE CLAIRE IA
52753
US

IV. Provider business mailing address

2543 TECH DR
BETTENDORF IA
52722-3263
US

V. Phone/Fax

Practice location:
  • Phone: 563-508-6330
  • Fax:
Mailing address:
  • Phone: 635-086-3305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number21364
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: