Basic Information
| Provider Information | |||||||||
| NPI: | 1629070636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADFORD | ||||||||
| FirstName: | VELMA | ||||||||
| MiddleName: | SUSAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LOWERY | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | BRADFORD | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3653 N. LOCUST GROVE ROAD | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083385437 | ||||||||
| FaxNumber: | 2089399811 | ||||||||
| Practice Location | |||||||||
| Address1: | 2275 S EAGLE RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836422620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085142520 | ||||||||
| FaxNumber: | 2083752217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 02/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | M7541 | ID | N | Other Service Providers | Legal Medicine | 208000000X | M-7541 | ID | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1629070636 | 05 | ID | MEDICAID | 805219300 | 05 | ID | MEDICAID |