Provider Demographics
NPI:1871772855
Name:BRADLEY W NORDYKE MD
Entity type:Organization
Organization Name:BRADLEY W NORDYKE MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:GUADALUPE
Authorized Official - Last Name:NORDYKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-982-1696
Mailing Address - Street 1:3914 PAREDES LINE RD
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78526-1184
Mailing Address - Country:US
Mailing Address - Phone:956-982-1696
Mailing Address - Fax:956-982-2256
Practice Address - Street 1:3914 PAREDES LINE RD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-1184
Practice Address - Country:US
Practice Address - Phone:956-982-1696
Practice Address - Fax:956-982-2256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-26
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7115208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00742RMedicare PIN