MEDICARE: BRADFORD THOMAS RILEY DO

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	208D00000X	General Practice Physician	0102205405	VA
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1548701089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADFORD THOMAS RILEY DO

Provider Business Mailing Address
First Line	:	PSC 561 BOX 1877
Second Line	:
City	:	FPO
State	:	AP
Zip	:	96310-0019
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	U.S. NMRTC YOKOSUKA
Second Line	:	MCAS IWAKUNI
City	:	FPO
State	:	AP
Zip	:	96310
Country	:	US
Telephone Number	:	315-243-8649
Fax Number	:

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

Provider Enumeration Date	:	03/16/2017
Last Update Date	:	09/16/2024

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