Provider Demographics
NPI:1144339276
Name:BRADLEY, DEWAYNE THOMAS (MD)
Entity type:Individual
Prefix:
First Name:DEWAYNE
Middle Name:THOMAS
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-1132
Mailing Address - Country:US
Mailing Address - Phone:206-329-1760
Mailing Address - Fax:
Practice Address - Street 1:904 7TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-1132
Practice Address - Country:US
Practice Address - Phone:206-329-1760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00043530207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00285478OtherRAILROAD MEDICARE
WA8392664Medicaid
WA0039572OtherLABOR & INDUSTRY
WAUS7329597OtherAETNA/USHC SPECIALIST
WA8050BROtherBLUE SHIELD
WA8050BROtherBLUE SHIELD
WA8392664Medicaid