Provider Demographics
NPI:1104159177
Name:BRADSHAW, ELIZABETH CORICH (DO)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:CORICH
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:406 PROVINCETOWN LN
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3421
Mailing Address - Country:US
Mailing Address - Phone:214-336-8540
Mailing Address - Fax:972-238-1448
Practice Address - Street 1:406 PROVINCETOWN LN
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3421
Practice Address - Country:US
Practice Address - Phone:214-336-8540
Practice Address - Fax:972-238-1448
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-09
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF6469202C00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical Examiner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC13693Medicare UPIN