Basic Information
| Provider Information | |||||||||
| NPI: | 1538125745 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IDELSHON | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | CURTIS | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 S BLOSSER RD | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934587310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053618028 | ||||||||
| FaxNumber: | 8053618097 | ||||||||
| Practice Location | |||||||||
| Address1: | 1057 E GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | ARROYO GRANDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934202504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052701700 | ||||||||
| FaxNumber: | 8054817097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 06/11/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A5884 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | FHC71031F | 05 | CA | MEDICAID | FHC71032F | 05 | CA | MEDICAID | HAP71031F | 01 | CA | FAMILY PACK | OTHER |