Healthcare Provider Details

I. General information

NPI: 1558476739
Provider Name (Legal Business Name): BRADLEY WILLIAM BUCKROP DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3727 46TH AVENUE BLACKHAWK RD STE 103
ROCK ISLAND IL
61201-7078
US

IV. Provider business mailing address

3727 46TH AVE STE 103
ROCK ISLAND IL
61201-7078
US

V. Phone/Fax

Practice location:
  • Phone: 309-788-3668
  • Fax: 309-786-5168
Mailing address:
  • Phone: 309-788-3668
  • Fax: 309-786-5168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number016004658
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number00545
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: