Provider Demographics
NPI:1407849219
Name:PRESTRIDGE, BARRY B (MD)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:B
Last Name:PRESTRIDGE
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 1:1 BURNSIDE
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-1123
Mailing Address - Country:US
Mailing Address - Phone:940-322-6953
Mailing Address - Fax:940-767-9301
Practice Address - Street 1:1 BURNSIDE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76310-1123
Practice Address - Country:US
Practice Address - Phone:940-322-6953
Practice Address - Fax:940-767-9301
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD8387207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122966801Medicaid
TX81E043Medicare PIN