Basic Information
| Provider Information | |||||||||
| NPI: | 1053607945 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STOVALL | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 BOULDERS PKWY | ||||||||
| Address2: | STE 200 | ||||||||
| City: | NORTH CHESTERFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232254067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8049154607 | ||||||||
| FaxNumber: | 8045609029 | ||||||||
| Practice Location | |||||||||
| Address1: | 11958 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | HENRICO | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232331007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8043604669 | ||||||||
| FaxNumber: | 8043646521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2011 | ||||||||
| LastUpdateDate: | 07/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 0102204430 | VA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 559509 | 01 | TX | TEXAS MEDICAL BOARD | OTHER |