Provider Demographics
NPI:1306455522
Name:BRADLEY, KEVIN (SOIDC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 13TH ST
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-4476
Mailing Address - Country:US
Mailing Address - Phone:910-465-5610
Mailing Address - Fax:
Practice Address - Street 1:903 13TH ST
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-4476
Practice Address - Country:US
Practice Address - Phone:910-465-5610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
1367445790OtherNAVY