Healthcare Provider Details

I. General information

NPI: 1891929238
Provider Name (Legal Business Name): MARK S. BRADLEY, M.D. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2009
Last Update Date: 05/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 GALISTEO ST
SANTA FE NM
87505-2101
US

IV. Provider business mailing address

2015 GALISTEO ST
SANTA FE NM
87505-2101
US

V. Phone/Fax

Practice location:
  • Phone: 505-466-2575
  • Fax: 505-989-1550
Mailing address:
  • Phone: 505-466-2575
  • Fax: 505-989-1550

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: MARK S BRADLEY
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 505-466-2575