Provider Demographics
NPI:1053607945
Name:STOVALL, BRADLEY ALAN (DO)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:ALAN
Last Name:STOVALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1115 BOULDERS PKWY
Mailing Address - Street 2:STE 200
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4067
Mailing Address - Country:US
Mailing Address - Phone:804-915-4607
Mailing Address - Fax:804-560-9029
Practice Address - Street 1:11958 W BROAD ST
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-1007
Practice Address - Country:US
Practice Address - Phone:804-360-4669
Practice Address - Fax:804-364-6521
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0102204430208100000X
VA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX559509OtherTEXAS MEDICAL BOARD