Healthcare Provider Details

I. General information

NPI: 1760914691
Provider Name (Legal Business Name): BRADLEY GILBERT MARPLE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 6TH AVE STE 101
MONTGOMERY WV
25136-2116
US

IV. Provider business mailing address

401 6TH AVE STE 101
MONTGOMERY WV
25136-2116
US

V. Phone/Fax

Practice location:
  • Phone: 304-442-7427
  • Fax:
Mailing address:
  • Phone: 304-442-7427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number3551
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: