Provider Demographics
NPI:1871568139
Name:TISDALE, BRADFORD W (MD)
Entity type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:W
Last Name:TISDALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3745 HOLLAND RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-2847
Mailing Address - Country:US
Mailing Address - Phone:757-962-8720
Mailing Address - Fax:757-507-9004
Practice Address - Street 1:3745 HOLLAND RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-2847
Practice Address - Country:US
Practice Address - Phone:757-962-8720
Practice Address - Fax:757-507-9004
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101034354207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005611695Medicaid
VA005611695Medicaid
080005960Medicare ID - Type Unspecified