Provider Demographics
NPI:1992724785
Name:POWERS, BRADLEY C (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:C
Last Name:POWERS
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 1:8237 RAVENDALE RD
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91775-1041
Mailing Address - Country:US
Mailing Address - Phone:626-292-7563
Mailing Address - Fax:
Practice Address - Street 1:801 S CHEVY CHASE DR STE 105
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-4432
Practice Address - Country:US
Practice Address - Phone:818-265-2200
Practice Address - Fax:818-265-2201
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63910207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7953469OtherAETNA
CAA63910OtherLICENSE
CABP5650583OtherDEA
CAWA63910BMedicare ID - Type UnspecifiedBURBANK
CABP5650583OtherDEA
CAG74804Medicare UPIN
CAWA63910AMedicare ID - Type UnspecifiedGLENDALE