Provider Demographics
NPI:1730226127
Name:BROWN, BRADLEY EDWARD
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:EDWARD
Last Name:BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 N STATE HIGHWAY 342
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75154-4607
Mailing Address - Country:US
Mailing Address - Phone:972-617-8830
Mailing Address - Fax:972-617-0006
Practice Address - Street 1:527 N STATE HIGHWAY 342
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:TX
Practice Address - Zip Code:75154-4607
Practice Address - Country:US
Practice Address - Phone:972-617-8830
Practice Address - Fax:972-617-0006
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5064111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX603015Medicare ID - Type Unspecified
TXT84763Medicare UPIN