Provider Demographics
NPI:1043086614
Name:ANDERSON, BRADLEY JOHN (MD, MS)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JOHN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 W 104TH ST APT 202
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-4363
Mailing Address - Country:US
Mailing Address - Phone:949-573-2714
Mailing Address - Fax:
Practice Address - Street 1:177 FORT WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3733
Practice Address - Country:US
Practice Address - Phone:917-658-5878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2025-06-24
Deactivation Date:2025-04-07
Deactivation Code:
Reactivation Date:2025-05-15
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program