Provider Demographics
NPI:1619197043
Name:LAITINEN, BRADLEY JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JOHN
Last Name:LAITINEN
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 1:20311 STONE PT
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-8668
Mailing Address - Country:US
Mailing Address - Phone:906-281-2265
Mailing Address - Fax:
Practice Address - Street 1:20311 STONE PT
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-8668
Practice Address - Country:US
Practice Address - Phone:906-281-2265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC56028207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OTH000Medicare UPIN