Basic Information
| Provider Information | |||||||||
| NPI: | 1205819125 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEBER | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7964 DEEP WOODS CT | ||||||||
| Address2: | |||||||||
| City: | SPRINGBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450668777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375547385 | ||||||||
| FaxNumber: | 9375547385 | ||||||||
| Practice Location | |||||||||
| Address1: | 7901 SCHATZ POINTE DR | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454593856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374390390 | ||||||||
| FaxNumber: | 9374397370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 01/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 34004205W | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 208D00000X | 34-004205 | OH | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 0748196 | 05 | OH | MEDICAID |