MEDICARE: DAVID LAMAR BRADSHAW D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	1772	OK

General Provider Information

NPI Number	:	1134426315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID LAMAR BRADSHAW D.O.

Provider Business Mailing Address
First Line	:	14421 S LIBBY ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73170-5719
Country	:	US
Telephone Number	:	405-691-2898
Fax Number	:	405-635-8380

Provider Business Practice Location Address
First Line	:	809 SW 89TH ST
Second Line	:	STE. C
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73139-9360
Country	:	US
Telephone Number	:	405-635-8378
Fax Number	:	405-635-8380

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2011
Last Update Date	:	02/23/2011

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