Provider Demographics
NPI:1902987019
Name:JOHN BRADLEY MD PC
Entity Type:Organization
Organization Name:JOHN BRADLEY MD PC
Other - Org Name:JOHN C BRADLEY, M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-460-8377
Mailing Address - Street 1:11017 DAYBREAK COURT
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4107
Mailing Address - Country:US
Mailing Address - Phone:301-460-8377
Mailing Address - Fax:301-460-3794
Practice Address - Street 1:13975 CONNECTICUT AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20906
Practice Address - Country:US
Practice Address - Phone:301-460-8377
Practice Address - Fax:301-460-3794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2009-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0014024207W00000X
DCMD5818207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC62163Medicare UPIN
MDG02508Medicare PIN