Basic Information
| Provider Information | |||||||||
| NPI: | 1568807055 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRADSHAW | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10140 CENTURION PKWY N | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322560532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046974127 | ||||||||
| FaxNumber: | 9046975102 | ||||||||
| Practice Location | |||||||||
| Address1: | MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271578426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2013 | ||||||||
| LastUpdateDate: | 10/28/2019 | ||||||||
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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 | 207L00000X | 2019-02392 | NC | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP3000X | ME129022 | FL | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 390200000X | 18347 | FL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 024846300 | 05 | FL | MEDICAID |