Provider Demographics
NPI:1124327267
Name:BRADFORD, GARY
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 N YORK ST
Mailing Address - Street 2:SUITE 20
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-3123
Mailing Address - Country:US
Mailing Address - Phone:918-913-9109
Mailing Address - Fax:918-913-9112
Practice Address - Street 1:928 N YORK ST
Practice Address - Street 2:SUITE 20
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-3123
Practice Address - Country:US
Practice Address - Phone:918-913-9109
Practice Address - Fax:918-913-9112
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-15
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes132700000XDietary & Nutritional Service ProvidersDietary Manager
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK380025Medicaid
OK100700630AMedicare PIN