Provider Demographics
NPI:1902127368
Name:BRADFORD, LAUREL (MD)
Entity Type:Individual
Prefix:DR
First Name:LAUREL
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19260 SW 65TH AVE
Mailing Address - Street 2:SUITE 340
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-5701
Mailing Address - Country:US
Mailing Address - Phone:503-691-9777
Mailing Address - Fax:
Practice Address - Street 1:19260 SW 65TH AVE
Practice Address - Street 2:SUITE 340
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-5701
Practice Address - Country:US
Practice Address - Phone:503-691-9777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD162128208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics