Provider Demographics
NPI:1154337988
Name:HEALTON, BRADLY (MD)
Entity type:Individual
Prefix:
First Name:BRADLY
Middle Name:
Last Name:HEALTON
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:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371-0609
Mailing Address - Country:US
Mailing Address - Phone:260-726-9027
Mailing Address - Fax:260-726-9529
Practice Address - Street 1:30000 WOODCREEK DR
Practice Address - Street 2:200B
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515
Practice Address - Country:US
Practice Address - Phone:636-087-4299
Practice Address - Fax:630-968-1622
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035433A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D94602Medicare UPIN