Healthcare Provider Details

I. General information

NPI: 1205071149
Provider Name (Legal Business Name): BRADLEY W. BUCKROP DPM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2008
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

3727 46TH AVE SUITE 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 TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number00545
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number01600458
License Number StateIL

VIII. Authorized Official

Name: BRADLEY WILLIAM BUCKROP
Title or Position: PODIATRIST/OWNER
Credential: DPM
Phone: 309-788-3668