Provider Demographics
NPI:1194729582
Name:LARSON, BRADLEY J G (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:J G
Last Name:LARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:531 ROSELANE ST NW STE 710
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-6975
Mailing Address - Country:US
Mailing Address - Phone:678-331-3297
Mailing Address - Fax:678-581-7187
Practice Address - Street 1:157 CLINIC AVE
Practice Address - Street 2:STE 101
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4413
Practice Address - Country:US
Practice Address - Phone:770-333-2220
Practice Address - Fax:678-581-7180
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2017-12-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA054449207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1194729582OtherNPI NUMBER
AL009950455Medicaid
GA184142314BMedicaid
GA184142314AMedicaid
GA184142314CMedicaid
GA184142314BMedicaid