Healthcare Provider Details

I. General information

NPI: 1215107255
Provider Name (Legal Business Name): BRADLEY CLARK GARDINER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 FITZSIMMONS DR MCHJ-PV- DEPARTMENT OF PREVENTIVE MEDICINE
TACOMA WA
98431-1000
US

IV. Provider business mailing address

9040 FITZSIMMONS DR MCHJ-PV- DEPARTMENT OF PREVENTIVE MEDICINE
TACOMA WA
98431-1000
US

V. Phone/Fax

Practice location:
  • Phone: 253-426-5082
  • Fax:
Mailing address:
  • Phone: 253-426-5082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberMD24659
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: