Healthcare Provider Details

I. General information

NPI: 1801107065
Provider Name (Legal Business Name): KELLY TODD BRADLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY ELIZABETH TODD M.D.

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 12/14/2022
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2864 BENNETTS POND RD
WILLIAMSBURG VA
23185-7549
US

IV. Provider business mailing address

2864 BENNETTS POND RD
WILLIAMSBURG VA
23185-7549
US

V. Phone/Fax

Practice location:
  • Phone: 617-733-5485
  • Fax:
Mailing address:
  • Phone: 617-733-5485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number34495
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number0101276609
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: