Provider Demographics
NPI:1861555724
Name:OSGOOD, BRADLEY KIMBALL (DC)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:KIMBALL
Last Name:OSGOOD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 KELLER ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-2943
Mailing Address - Country:US
Mailing Address - Phone:707-775-2501
Mailing Address - Fax:
Practice Address - Street 1:135 KELLER ST
Practice Address - Street 2:SUITE A
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2943
Practice Address - Country:US
Practice Address - Phone:707-775-2501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24930111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU70124Medicare UPIN
CA0249300Medicare ID - Type UnspecifiedMEDICARE NUMBER