Provider Demographics
NPI:1528123254
Name:BRADFORD, DANIEL JOHN (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOHN
Last Name:BRADFORD
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 1:650 SIERRA ROSE DR STE B
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-2081
Mailing Address - Country:US
Mailing Address - Phone:775-443-1530
Mailing Address - Fax:
Practice Address - Street 1:650 SIERRA ROSE DR STE B
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-2081
Practice Address - Country:US
Practice Address - Phone:775-443-1530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV23000207Q00000X
CAG60671207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI53792001Medicaid
HI00A0241552OtherHMSA
CABS374ZMedicaid
HI00A0241552OtherHMSA