Healthcare Provider Details

I. General information

NPI: 1932369832
Provider Name (Legal Business Name): PAUL R BRADLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 E MARSHALL AVE STE 5008
LONGVIEW TX
75601-5557
US

IV. Provider business mailing address

PO BOX 846098
DALLAS TX
75284-6098
US

V. Phone/Fax

Practice location:
  • Phone: 903-315-4455
  • Fax: 903-315-2466
Mailing address:
  • Phone: 903-315-4105
  • Fax: 903-315-4130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN12267
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberP6344
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: