Provider Demographics
NPI:1043207939
Name:MEYER, BRADLEY RUSSELL (DO)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:RUSSELL
Last Name:MEYER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:2301 HIGHWAY 71 STE C
Mailing Address - Street 2:
Mailing Address - City:SPIRIT LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:51360-1184
Mailing Address - Country:US
Mailing Address - Phone:712-336-3750
Mailing Address - Fax:712-336-3730
Practice Address - Street 1:2301 HIGHWAY 71 STE C
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360-1184
Practice Address - Country:US
Practice Address - Phone:712-336-3750
Practice Address - Fax:712-336-3730
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO-04161207Q00000X
NE5262207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1043207939Medicaid
IA719260392Medicare PIN