Healthcare Provider Details

I. General information

NPI: 1205459054
Provider Name (Legal Business Name): BRADLEY NATHANIEL MALLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MARTHA JEFFERSON DR STE 315A
CHARLOTTESVILLE VA
22911-4668
US

IV. Provider business mailing address

500 MARTHA JEFFERSON DR STE 315A
CHARLOTTESVILLE VA
22911-4668
US

V. Phone/Fax

Practice location:
  • Phone: 434-654-8390
  • Fax: 434-654-8399
Mailing address:
  • Phone: 434-654-8390
  • Fax: 434-654-8399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number0116034551
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: