Healthcare Provider Details

I. General information

NPI: 1770994030
Provider Name (Legal Business Name): BRADLEY DEERE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2014
Last Update Date: 03/02/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

504 CLINTON CENTER DRIVE CBO-SUITE 4300
JACKSON MS
39056
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-2005
  • Fax: 601-815-0434
Mailing address:
  • Phone: 601-496-9794
  • Fax: 601-815-0434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number27203
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: