Provider Demographics
NPI:1063533412
Name:POTSIC, BRADLEY JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JOHN
Last Name:POTSIC
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 1:2950 CLEVELAND CLINIC BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33331-3625
Mailing Address - Country:US
Mailing Address - Phone:954-689-5123
Mailing Address - Fax:954-689-5115
Practice Address - Street 1:2950 CLEVELAND CLINIC BLVD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3625
Practice Address - Country:US
Practice Address - Phone:954-689-5123
Practice Address - Fax:954-689-5115
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1214672085R0202X
NV148052085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVP01224603OtherRR MEDICARE
NVP01250080OtherRR MEDICARE DR
CA1063533412Medicaid
NV1063533412Medicaid
CA1063533412Medicaid
NVP01224603OtherRR MEDICARE
NVHH894YMedicare PIN