Individual
DR. BRADLEY CANADA DINER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
4 EXECUTIVE CENTER CT, LITTLE ROCK, AR 72211-4487
(501) 448-0060
(501) 448-0066
Mailing address
4 EXECUTIVE CENTER CT, LITTLE ROCK, AR 72211-4487
(501) 448-0060
(501) 448-0066
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
C6817
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
117612001
—
AR
01
—
53985
BLUE CROSS BLUE SHIELD
AR
Enumeration date
03/14/2006
Last updated
03/18/2013
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