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NPI Code Detail

MEDICARE: DR. BRADFORD W TISDALE M.D.

MEDICARE: DR. BRADFORD W TISDALE M.D.
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
1207Q00000XFamily Medicine Physician0101034354VA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1871568139
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. BRADFORD W TISDALE M.D.
Provider Business Mailing Address
First Line : 3745 HOLLAND RD
Second Line :
City : VIRGINIA BEACH
State : VA
Zip : 23452-2847
Country : US
Telephone Number : 757-962-8720
Fax Number : 757-507-9004
Provider Business Practice Location Address
First Line : 3745 HOLLAND RD
Second Line :
City : VIRGINIA BEACH
State : VA
Zip : 23452-2847
Country : US
Telephone Number : 757-962-8720
Fax Number : 757-507-9004
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/21/2006
Last Update Date : 12/27/2013

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