Provider Demographics
NPI:1366588261
Name:ENGWALL, BRADLEY J (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:J
Last Name:ENGWALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2020 MILVIA ST
Mailing Address - Street 2:STE 450
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-2685
Mailing Address - Country:US
Mailing Address - Phone:510-559-1819
Mailing Address - Fax:510-559-1819
Practice Address - Street 1:2020 MILVIA ST
Practice Address - Street 2:STE 450
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-2685
Practice Address - Country:US
Practice Address - Phone:510-559-1819
Practice Address - Fax:510-559-1819
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA624772084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
H34280Medicare UPIN