Provider Demographics
NPI:1144293044
Name:BRIDEWELL, BRUCE MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:MICHAEL
Last Name:BRIDEWELL
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:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33929-1209
Mailing Address - Country:US
Mailing Address - Phone:239-992-7822
Mailing Address - Fax:239-947-5687
Practice Address - Street 1:10201 ARCOS AVE
Practice Address - Street 2:STE 201
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-9459
Practice Address - Country:US
Practice Address - Phone:239-992-7822
Practice Address - Fax:239-947-5687
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51156207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL263210100Medicaid
FLK2012OtherMEDICARE GROUP
FL19146-1OtherFAA
FL07931VMedicare ID - Type Unspecified
FLK2012OtherMEDICARE GROUP