Healthcare Provider Details

I. General information

NPI: 1962438739
Provider Name (Legal Business Name): ALVIN J. BRADFORD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 04/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 S TELEPHONE RD STE 250
MOORE OK
73160-2969
US

IV. Provider business mailing address

1412 FAIRMOUNT AVE
PHILADELPHIA PA
19130-2908
US

V. Phone/Fax

Practice location:
  • Phone: 215-840-2658
  • Fax:
Mailing address:
  • Phone: 215-840-2658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS10692
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS012606
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: