Provider Demographics
NPI:1972284917
Name:BRADSHAW, MYLES
Entity type:Individual
Prefix:
First Name:MYLES
Middle Name:
Last Name:BRADSHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5852 E BONIWOOD TURN
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-4828
Mailing Address - Country:US
Mailing Address - Phone:301-537-1887
Mailing Address - Fax:
Practice Address - Street 1:2218 RHODE ISLAND AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-2827
Practice Address - Country:US
Practice Address - Phone:202-717-9323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker