Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | DN 20845 | FL |
Y | 213EG0000X | General Practice | DN 20845 | FL |
NPI | 1003224148 |
---|---|
Provider Name | Alijah Bradley |
First Address | Miami, FL 33179-5936 |
Second Address | Tamarac, FL 33319-3305 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/07/2014 |
Last Update Date | 29/10/2014 |