Provider Demographics
NPI:1962711036
Name:BRADLEY, LARRY EDWIN (DO)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:EDWIN
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7016 RIVERPORT RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-9311
Mailing Address - Country:US
Mailing Address - Phone:817-738-4288
Mailing Address - Fax:
Practice Address - Street 1:7016 RIVERPORT RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-9311
Practice Address - Country:US
Practice Address - Phone:817-738-4288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-06
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6067208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice