1821292590 NPI number — DR. MELISSA R BRADLEY D.O.

Table of content: DR. MELISSA R BRADLEY D.O. (NPI 1821292590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821292590 NPI number — DR. MELISSA R BRADLEY D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADLEY
Provider First Name:
MELISSA
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REYNOLDS
Provider Other First Name:
MELISSA
Provider Other Middle Name:
C
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1821292590
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2424 N. WYATT DRIVE
Provider Second Line Business Mailing Address:
SECOND FLOOR
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-545-0608
Provider Business Mailing Address Fax Number:
520-795-0354

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6565 E. CARONDELET DRIVE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85710-2158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-323-0333
Provider Business Practice Location Address Fax Number:
520-323-5036
Provider Enumeration Date:
06/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  0102202751 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 6352 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 930677 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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