Healthcare Provider Details

I. General information

NPI: 1962494757
Provider Name (Legal Business Name): BRADLEY G TITUS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 THOMPSON RD
COOS BAY OR
97420-2125
US

IV. Provider business mailing address

PO BOX 1398
WALLA WALLA WA
99362-0309
US

V. Phone/Fax

Practice location:
  • Phone: 541-269-8111
  • Fax:
Mailing address:
  • Phone: 509-527-8154
  • Fax: 509-527-8010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD00024594
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberMD00024594
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: