Provider Demographics
NPI:1730112145
Name:WATLING, BRADLEY (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:WATLING
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 1:3101 LATROBE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-4849
Mailing Address - Country:US
Mailing Address - Phone:704-376-7362
Mailing Address - Fax:
Practice Address - Street 1:3101 LATROBE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4849
Practice Address - Country:US
Practice Address - Phone:704-376-7362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900383207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891230TMedicaid
SCN00383Medicaid
NC891230TMedicaid
NC2279664AMedicare ID - Type Unspecified