Healthcare Provider Details

I. General information

NPI: 1699185256
Provider Name (Legal Business Name): BRADLEY DEKORTE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 BLACK OAK DR STE 300B
MEDFORD OR
97504-8491
US

IV. Provider business mailing address

2620 E BARNETT RD STE H
MEDFORD OR
97504-8383
US

V. Phone/Fax

Practice location:
  • Phone: 541-789-8100
  • Fax: 541-789-8101
Mailing address:
  • Phone: 541-789-2559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOL60476473
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP60576320
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO181937
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License NumberDO181937
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: