Healthcare Provider Details

I. General information

NPI: 1306800412
Provider Name (Legal Business Name): BRADLEY A PONTANI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 W 32ND ST SUITE 103
JOPLIN MO
64804-1529
US

IV. Provider business mailing address

1905 W 32ND ST STE #103
JOPLIN MO
64804-1529
US

V. Phone/Fax

Practice location:
  • Phone: 417-556-2185
  • Fax:
Mailing address:
  • Phone: 417-556-2185
  • Fax: 417-556-6968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG5492
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License NumberG5492
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberG5492
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: