Healthcare Provider Details

I. General information

NPI: 1497786867
Provider Name (Legal Business Name): MARK STEPHEN BRADLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 ASPEN DR STE 500B
SANTA FE NM
87505-5495
US

IV. Provider business mailing address

1925 ASPEN DR STE 500B
SANTA FE NM
87505-5495
US

V. Phone/Fax

Practice location:
  • Phone: 505-466-2575
  • Fax: 505-466-2575
Mailing address:
  • Phone: 505-466-2575
  • Fax: 505-466-2575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number2002-0015
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: