Provider Demographics
NPI:1699746446
Name:BRADLEY, STEPHEN PETER (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:PETER
Last Name:BRADLEY
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 1:5375 LAKESHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-6123
Mailing Address - Country:US
Mailing Address - Phone:707-263-5679
Mailing Address - Fax:707-263-7781
Practice Address - Street 1:5375 LAKESHORE BLVD
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-6123
Practice Address - Country:US
Practice Address - Phone:707-263-5679
Practice Address - Fax:707-263-7781
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC41489208600000X, 208D00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C414890Medicaid
CAD77180Medicare UPIN
CA00C414890Medicaid