Basic Information
Provider Information | |||||||||
NPI: | 1699185256 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEKORTE | ||||||||
FirstName: | BRADLEY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2620 E BARNETT RD STE H | ||||||||
Address2: |   | ||||||||
City: | MEDFORD | ||||||||
State: | OR | ||||||||
PostalCode: | 975048383 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5417892559 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 520 SW RAMSEY AVE | ||||||||
Address2: |   | ||||||||
City: | GRANTS PASS | ||||||||
State: | OR | ||||||||
PostalCode: | 975275535 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5414727810 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/05/2014 | ||||||||
LastUpdateDate: | 11/06/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OL60476473 | WA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | OP60576320 | WA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | DO181937 | OR | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2035866 | 05 | WA |   | MEDICAID |