Provider Demographics
NPI:1881714517
Name:BRADLEY, CECIL ARTHUR (MD)
Entity type:Individual
Prefix:
First Name:CECIL
Middle Name:ARTHUR
Last Name:BRADLEY
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 1:2512 SAMARITAN CT
Mailing Address - Street 2:STE M
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-4002
Mailing Address - Country:US
Mailing Address - Phone:408-997-9648
Mailing Address - Fax:408-997-9645
Practice Address - Street 1:2512 SAMARITAN CT
Practice Address - Street 2:SUITE M
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4002
Practice Address - Country:US
Practice Address - Phone:408-356-3663
Practice Address - Fax:650-347-7671
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC341332084P0802X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA35513Medicare UPIN