MEDICARE: BRADLEY DONALD TOURTLOTTE MD

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	G-076763	CA

General Provider Information

NPI Number	:	1902955859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY DONALD TOURTLOTTE MD

Provider Business Mailing Address
First Line	:	7020 BURNING TREE CT
Second Line	:
City	:	RIVERBANK
State	:	CA
Zip	:	95367-3328
Country	:	US
Telephone Number	:	209-613-9669
Fax Number	:

Provider Business Practice Location Address
First Line	:	3663 ARCH RD
Second Line	:	SUITE 400
City	:	STOCKTON
State	:	CA
Zip	:	95215-8315
Country	:	US
Telephone Number	:	209-943-2202
Fax Number	:	209-943-2209

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

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	07/08/2007

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