Basic Information
| Provider Information | |||||||||
| NPI: | 1518958743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEAL | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | KENNETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13 MAIN STREET | ||||||||
| Address2: | SAN QUENTIN PRISON | ||||||||
| City: | SAN QUENTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154541460 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13 MAIN ST. | ||||||||
| Address2: | SAN QUENTIN PRISON | ||||||||
| City: | SAN QUENTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154541460 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2005 | ||||||||
| LastUpdateDate: | 03/15/2012 | ||||||||
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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 | 2084P0800X | ME94046 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | A102530 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | ME94046 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0804X | A102530 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 276684100 | 05 | FL | MEDICAID |