Provider Demographics
NPI:1043437213
Name:MOSS, BRIDGETT R (DO)
Entity Type:Individual
Prefix:
First Name:BRIDGETT
Middle Name:R
Last Name:MOSS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:11430 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3414
Mailing Address - Country:US
Mailing Address - Phone:262-518-1900
Mailing Address - Fax:262-518-5052
Practice Address - Street 1:11430 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3414
Practice Address - Country:US
Practice Address - Phone:262-518-1900
Practice Address - Fax:262-518-5052
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI50193207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI50193OtherSTATE MEDICAL LICENSE
WI50193OtherSTATE MEDICAL LICENSE