Provider Demographics
NPI:1669047601
Name:BRADFORD, GUSTAVIA
Entity type:Individual
Prefix:
First Name:GUSTAVIA
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6240 BELCHER OIL CITY RD
Mailing Address - Street 2:
Mailing Address - City:BELCHER
Mailing Address - State:LA
Mailing Address - Zip Code:71004-0134
Mailing Address - Country:US
Mailing Address - Phone:318-426-6976
Mailing Address - Fax:
Practice Address - Street 1:6240 BELCHER OIL CITY RD
Practice Address - Street 2:
Practice Address - City:BELCHER
Practice Address - State:LA
Practice Address - Zip Code:71004-7100
Practice Address - Country:US
Practice Address - Phone:318-426-6976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA005971290347B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347B00000XTransportation ServicesBus
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA86-3750549Medicaid