Basic Information
| Provider Information | |||||||||
| NPI: | 1790133999 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIRTH | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | JONATHAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BIRTH | ||||||||
| OtherFirstName: | BRAD | ||||||||
| OtherMiddleName: | JONATHAN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 104 SELMA DR | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226013834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406782853 | ||||||||
| FaxNumber: | 5406782859 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 W 11TH ST | ||||||||
| Address2: | |||||||||
| City: | FRONT ROYAL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226303512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406313700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2016 | ||||||||
| LastUpdateDate: | 05/29/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0116029013 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.