Provider Demographics
NPI:1225162779
Name:BRIDGES, LEONARD WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:WAYNE
Last Name:BRIDGES
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 1240
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:MO
Mailing Address - Zip Code:65653-1240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:256 STATE HIGHWAY Y
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:MO
Practice Address - Zip Code:65653-5618
Practice Address - Country:US
Practice Address - Phone:417-546-4200
Practice Address - Fax:417-546-4505
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114104208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0184796OtherWA STATE LABOR UNION
MO121791OtherBLUE CROSS BLUE SHIELD
WA0184796OtherWA STATE LABOR UNION