Provider Demographics
NPI:1386622645
Name:MONTIERTH, BRADFORD N (MD)
Entity type:Individual
Prefix:
First Name:BRADFORD
Middle Name:N
Last Name:MONTIERTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 S. 20TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546
Mailing Address - Country:US
Mailing Address - Phone:928-428-3122
Mailing Address - Fax:928-428-7917
Practice Address - Street 1:1300 S. 20TH AVENUE
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546
Practice Address - Country:US
Practice Address - Phone:928-428-3122
Practice Address - Fax:928-428-7917
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27148207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ467383Medicaid
Z66652Medicare PIN
AZ467383Medicaid
66652Medicare ID - Type Unspecified