Provider Demographics
NPI:1063613735
Name:HAMMETT, BRADLEY KYLE (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:KYLE
Last Name:HAMMETT
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 1:816 W CANNON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3146
Mailing Address - Country:US
Mailing Address - Phone:817-321-0404
Mailing Address - Fax:
Practice Address - Street 1:5016 S US HIGHWAY 75
Practice Address - Street 2:RADIOLOGY DEPT
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-4584
Practice Address - Country:US
Practice Address - Phone:903-892-1131
Practice Address - Fax:903-327-8023
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA372632085R0202X
OK261842085R0202X
IAR-69542085R0202X
TXM93412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200133330Medicaid
IA55046OtherWELLMARK BCBS
TX194365601Medicaid
TX194365601Medicaid
OKPTAN-OK-400651Medicare PIN
OKPTAN OK 400651Medicare PIN
IAP00427881Medicare PIN
OK200133330Medicaid
TXPTAN 8K8109Medicare PIN