Healthcare Provider Details

I. General information

NPI: 1063664530
Provider Name (Legal Business Name): BRADLEY B PUA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2008
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E 68TH ST PAYSON PAVILION 5
NEW YORK NY
10065-4870
US

IV. Provider business mailing address

525 E 68TH ST PAYSON PAVILION 5
NEW YORK NY
10065-4870
US

V. Phone/Fax

Practice location:
  • Phone: 212-746-2681
  • Fax: 212-746-8463
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number239766
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: