Basic Information
| Provider Information | |||||||||
| NPI: | 1093791964 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADFORD | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ADDITON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43 WHITING HILL RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | BREWER | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044121006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079735035 | ||||||||
| FaxNumber: | 2079735042 | ||||||||
| Practice Location | |||||||||
| Address1: | 925 UNION ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044013051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079739980 | ||||||||
| FaxNumber: | 2079737515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 01/29/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 011526 | ME | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | D03693 | 01 | ME | HARVARD PILGRIM | OTHER | M57740 | 01 | ME | CIGNA | OTHER | 1044474 | 01 | ME | AETNA | OTHER | 002921 | 01 | ME | BLUES | OTHER | 100289800 | 01 | ME | US DEPT OF LABOR | OTHER | 116170000 | 05 | ME | MEDICAID | 200002275 | 01 | ME | MEDICARE RAILROAD | OTHER |