Provider Demographics
NPI:1871777664
Name:TONDA D BRADSHAW D O A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:TONDA D BRADSHAW D O A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TONDA
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-790-6200
Mailing Address - Street 1:35237 YUCAIPA BLVD
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-4340
Mailing Address - Country:US
Mailing Address - Phone:909-790-6200
Mailing Address - Fax:909-790-6220
Practice Address - Street 1:35237 YUCAIPA BLVD
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-4340
Practice Address - Country:US
Practice Address - Phone:909-790-6200
Practice Address - Fax:909-790-6220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF80329Medicare UPIN
CAZZZ23890ZMedicare PIN