Provider Demographics
NPI:1306842919
Name:BRIDGEMAN, DEONA LYNN (MD)
Entity Type:Individual
Prefix:MRS
First Name:DEONA
Middle Name:LYNN
Last Name:BRIDGEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 N GRANT ST
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-3610
Mailing Address - Country:US
Mailing Address - Phone:503-266-2066
Mailing Address - Fax:503-263-8719
Practice Address - Street 1:345 N GRANT ST
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-3610
Practice Address - Country:US
Practice Address - Phone:503-266-2066
Practice Address - Fax:503-263-8719
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22254207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR107077OtherMEDICARE PTAN
OR288321Medicaid
ORR107077OtherMEDICARE PTAN