MEDICARE: DR. BRADLEY LAWRENCE DPM

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	213ES0103X	Foot & Ankle Surgery Podiatrist	2390	TX

General Provider Information

NPI Number	:	1235636721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY LAWRENCE DPM

Provider Business Mailing Address
First Line	:	2408 BURROUGHS MILL CIR
Second Line	:
City	:	CHERRY HILL
State	:	NJ
Zip	:	08002-1280
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3301 S ALAMEDA ST STE 306
Second Line	:
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78411-1876
Country	:	US
Telephone Number	:	361-884-3984
Fax Number	:	361-452-3262

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

Provider Enumeration Date	:	04/10/2018
Last Update Date	:	07/16/2019

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