Basic Information
| Provider Information | |||||||||
| NPI: | 1144339276 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | DEWAYNE | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 904 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981041132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063291760 | ||||||||
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| Practice Location | |||||||||
| Address1: | 904 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981041132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063291760 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 04/18/2012 | ||||||||
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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 | 207Y00000X | MD00043530 | WA | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | P00285478 | 01 | RAILROAD MEDICARE | OTHER | 8392664 | 05 | WA | MEDICAID | 0039572 | 01 | WA | LABOR & INDUSTRY | OTHER | US7329597 | 01 | WA | AETNA/USHC SPECIALIST | OTHER | 8050BR | 01 | WA | BLUE SHIELD | OTHER |