Provider Demographics
NPI:1083794648
Name:PRIDGEN, BRYANT CAMERON (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYANT
Middle Name:CAMERON
Last Name:PRIDGEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508A HARDEMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-1416
Mailing Address - Country:US
Mailing Address - Phone:478-755-1976
Mailing Address - Fax:478-755-1116
Practice Address - Street 1:1508A HARDEMAN AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1416
Practice Address - Country:US
Practice Address - Phone:478-755-1976
Practice Address - Fax:478-755-1116
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032459174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE64766Medicare UPIN