Healthcare Provider Details

I. General information

NPI: 1134562762
Provider Name (Legal Business Name): BRADLEY GORDAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2013
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 ARCADE AVE STE 320
ELKHART IN
46514-2477
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 574-523-7900
  • Fax: 574-523-7909
Mailing address:
  • Phone: 574-647-2129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number02006650A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: