Provider Demographics
NPI:1467291518
Name:BRADLEY W. SMITH, D.O., PLLC
Entity type:Organization
Organization Name:BRADLEY W. SMITH, D.O., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:W
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:719-252-3578
Mailing Address - Street 1:44 BRIARGATE TER
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1743
Mailing Address - Country:US
Mailing Address - Phone:719-252-3578
Mailing Address - Fax:719-546-6111
Practice Address - Street 1:1710 JET STREAM DR STE 215
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80921-3937
Practice Address - Country:US
Practice Address - Phone:719-546-6300
Practice Address - Fax:719-546-6111
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRADLEY W SMITH D.O., PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO21159335Medicaid