Healthcare Provider Details

I. General information

NPI: 1831127877
Provider Name (Legal Business Name): LOUISE BRADSHAW MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 04/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4024A OLD TAR RD
WINTERVILLE NC
28590-8430
US

IV. Provider business mailing address

4024A OLD TAR RD
WINTERVILLE NC
28590-8430
US

V. Phone/Fax

Practice location:
  • Phone: 252-355-3773
  • Fax: 252-355-1958
Mailing address:
  • Phone: 252-355-3773
  • Fax: 252-355-1958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number00-32643
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: