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General NPI Number Information
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NPI Number | 1265429310
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Entity Type | Individual
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Provider Name | BRADLEY GLENN JANN D.P.M
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Gender | Male
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Dates
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Enumeration Date | 10/04/2005
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Last Update Date | 07/25/2016
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Provider Practice Location Address
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Address Line | 100 THORNDALE DR MEDICAL CLINIC
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City | SAN RAFAEL
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State | CA
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Zip | 94903-4501
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Country | US
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Telephone | 415-461-5995
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Fax | 415-461-5995
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Provider Business Mailing Address
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Address Line | PO BOX 751347
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City | PETALUMA
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State | CA
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Zip | 94975-1347
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Country | US
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Telephone | 415-461-5995
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Fax | 707-545-1783
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | E3865
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License Number State | CA
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