=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578918520
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADLEY TRINIDAD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2016
-----------------------------------------------------
Last Update Date | 06/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 S COULTER ST STE 200
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79106-1765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-340-0550
-----------------------------------------------------
Fax | 806-513-6790
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 405 LONDONDERRY DR STE 310
-----------------------------------------------------
City | WACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76712-7922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-741-6333
-----------------------------------------------------
Fax | 806-513-6790
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number | R75495
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number | S9814
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------