Provider Demographics
NPI:1154577088
Name:BRADLEY, PAUL (DO)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:DO
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 2839
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-2839
Mailing Address - Country:US
Mailing Address - Phone:601-703-3480
Mailing Address - Fax:601-703-0124
Practice Address - Street 1:1521 22ND AVE
Practice Address - Street 2:A
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4016
Practice Address - Country:US
Practice Address - Phone:601-703-3830
Practice Address - Fax:601-553-2069
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS220802084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03735301Medicaid