Provider Demographics
NPI:1932720562
Name:SHANE, BRADLEY RUSSELL (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:RUSSELL
Last Name:SHANE
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1260 15TH ST STE 1024
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1145
Practice Address - Country:US
Practice Address - Phone:424-259-8570
Practice Address - Fax:424-259-6180
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA1946802084N0400X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology