Basic Information
| Provider Information | |||||||||
| NPI: | 1053570903 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | BRAD | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2828 N NATIONAL AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658034306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178374000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2828 N NATIONAL AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658034306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178374000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2008 | ||||||||
| LastUpdateDate: | 04/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 00319 | KY | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | 2009018603 | MO | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1053570903 | 05 | MO | MEDICAID | P00767556 | 01 | RR MEDICARE | OTHER |