Provider Demographics
NPI:1508340530
Name:BRIDGES, DURAL
Entity Type:Individual
Prefix:
First Name:DURAL
Middle Name:
Last Name:BRIDGES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8841 COYTH LN
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-6346
Mailing Address - Country:US
Mailing Address - Phone:318-207-1970
Mailing Address - Fax:
Practice Address - Street 1:8841 COYTH LN
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-6346
Practice Address - Country:US
Practice Address - Phone:318-207-1970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-15
Last Update Date:2018-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver