Provider Demographics
NPI:1548701089
Name:RILEY, BRADFORD THOMAS (DO)
Entity type:Individual
Prefix:
First Name:BRADFORD
Middle Name:THOMAS
Last Name:RILEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 561 BOX 1877
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96310-0019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:U.S. NMRTC YOKOSUKA
Practice Address - Street 2:MCAS IWAKUNI
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96310
Practice Address - Country:US
Practice Address - Phone:315-243-8649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102205405208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program