Provider Demographics
NPI:1720093495
Name:BOWER, BRADLEY BLAKE (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:BLAKE
Last Name:BOWER
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:FILE # 54433
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-4433
Mailing Address - Country:US
Mailing Address - Phone:858-784-5645
Mailing Address - Fax:858-784-5644
Practice Address - Street 1:550 WASHINGTON ST
Practice Address - Street 2:STE # 601
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2213
Practice Address - Country:US
Practice Address - Phone:619-944-4130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85574207R00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF33238Medicare UPIN