Basic Information
| Provider Information | |||||||||
| NPI: | 1790076222 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | DEREK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 802 S JACKSON AVE STE 505 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741279060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187475322 | ||||||||
| FaxNumber: | 9187467604 | ||||||||
| Practice Location | |||||||||
| Address1: | 802 S JACKSON AVE | ||||||||
| Address2: | #505 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741279015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187475322 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2011 | ||||||||
| LastUpdateDate: | 02/12/2019 | ||||||||
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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 | 208600000X | 5188 | OK | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200449100A | 05 | OK | MEDICAID |