Healthcare Provider Details

I. General information

NPI: 1104866714
Provider Name (Legal Business Name): CHARLES MARSHALL BRADSHAW M.D., P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2941 OAK PARK CIR STE 200
FORT WORTH TX
76109-1852
US

IV. Provider business mailing address

601 OMEGA DR SUITE 206
ARLINGTON TX
76014-2075
US

V. Phone/Fax

Practice location:
  • Phone: 817-332-7433
  • Fax: 817-394-6282
Mailing address:
  • Phone: 817-465-5881
  • Fax: 817-465-6336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberD2367
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberD2367
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: