Provider Demographics
NPI:1194740217
Name:BRADFORD, LETITIA L (MD)
Entity type:Individual
Prefix:
First Name:LETITIA
Middle Name:L
Last Name:BRADFORD
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 RED ROCK DR
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5683
Mailing Address - Country:US
Mailing Address - Phone:505-863-7309
Mailing Address - Fax:
Practice Address - Street 1:1901 RED ROCK DR
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5683
Practice Address - Country:US
Practice Address - Phone:505-863-7309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70194207X00000X
NHLT-2827207X00000X
NH14581207X00000X
NMMD2020-0288207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A701940Medicaid
NM08754331Medicaid
NH30208936Medicaid
CA00A701940Medicaid
CA00A701940Medicare PIN