Provider Demographics
NPI:1104800143
Name:PHILLIPS, BRADLEY J (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:J
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:450 CLARKSON AVE
Mailing Address - Street 2:BOX 1262
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2056
Mailing Address - Country:US
Mailing Address - Phone:718-270-8867
Mailing Address - Fax:718-270-1794
Practice Address - Street 1:450 CLARKSON AVE
Practice Address - Street 2:SUITE J
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2056
Practice Address - Country:US
Practice Address - Phone:718-270-1714
Practice Address - Fax:718-270-3233
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2007-09-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY184083-1207W00000X
NJ25MA06584600207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01278495Medicaid
NJ7384009Medicaid
NY01278495Medicaid
NY68F692Medicare ID - Type Unspecified
NYE69862Medicare UPIN