Provider Demographics
NPI:1073677977
Name:BRADLEY, JASON THOMAS (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:THOMAS
Last Name:BRADLEY
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 1:4324 23RD ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1812
Mailing Address - Country:US
Mailing Address - Phone:806-686-3500
Mailing Address - Fax:806-701-4184
Practice Address - Street 1:4321 MARSHA SHARP FWY
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79407-2504
Practice Address - Country:US
Practice Address - Phone:806-686-3500
Practice Address - Fax:806-701-4973
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1532207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM14984032Medicaid
TX148315812Medicaid
P01690378OtherRAILROAD MEDICARE PTAN
NM14984032Medicaid