Provider Demographics
NPI:1548355175
Name:MARSH, BRADLEY JAY (DPM)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JAY
Last Name:MARSH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:35 CHESTNUT HILL DR
Mailing Address - Street 2:
Mailing Address - City:OYSTER BAY
Mailing Address - State:NY
Mailing Address - Zip Code:11771-2508
Mailing Address - Country:US
Mailing Address - Phone:516-641-2536
Mailing Address - Fax:516-674-3707
Practice Address - Street 1:182-19 HORACE HARDING EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365
Practice Address - Country:US
Practice Address - Phone:718-670-2672
Practice Address - Fax:516-437-4167
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004776213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU33367Medicare UPIN
NY03475LMedicare ID - Type Unspecified