Healthcare Provider Details

I. General information

NPI: 1689669301
Provider Name (Legal Business Name): DOUGLAS L BRADLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 01/24/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17067 S OUTER RD SUITE 100
BELTON MO
64012-2165
US

IV. Provider business mailing address

17067 S OUTER RD SUITE 100
BELTON MO
64012-2165
US

V. Phone/Fax

Practice location:
  • Phone: 816-331-4000
  • Fax: 816-331-3626
Mailing address:
  • Phone: 816-331-4000
  • Fax: 816-331-3626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD R5B55
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: