Provider Demographics
NPI:1386604825
Name:WASSON, BRADLEY (DO)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:WASSON
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 1:400 W ARBROOK BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76014-3180
Mailing Address - Country:US
Mailing Address - Phone:817-960-9137
Mailing Address - Fax:
Practice Address - Street 1:400 W ARBROOK BLVD STE 300
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-3180
Practice Address - Country:US
Practice Address - Phone:817-960-9137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1584207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115384302Medicaid
TX115384302Medicaid
TX81W624Medicare ID - Type Unspecified