Healthcare Provider Details

I. General information

NPI: 1457302135
Provider Name (Legal Business Name): BRADLEY ALLWIN MCDONALD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 ASH ST
SPOONER WI
54801-1201
US

IV. Provider business mailing address

14724 480TH AVE
MILBANK SD
57252-5925
US

V. Phone/Fax

Practice location:
  • Phone: 715-635-2111
  • Fax:
Mailing address:
  • Phone: 605-432-5852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39414-020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number40575
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4366
License Number StateSD
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30546
License Number StateIA
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9796
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: