Provider Demographics
NPI:1568405207
Name:WALSH, BRIDGET ANA (DO)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:ANA
Last Name:WALSH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 FOXFIRE CIR
Mailing Address - Street 2:
Mailing Address - City:ELBERTON
Mailing Address - State:GA
Mailing Address - Zip Code:30635-2616
Mailing Address - Country:US
Mailing Address - Phone:706-248-1300
Mailing Address - Fax:
Practice Address - Street 1:1 CHOCTAW WAY
Practice Address - Street 2:
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571-2022
Practice Address - Country:US
Practice Address - Phone:918-567-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034977207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000471336OMedicaid
SCG34977Medicaid
GA000471336NMedicaid
GAE19450Medicare UPIN
SCG34977Medicaid
GA93BBJRZMedicare ID - Type Unspecified
GA000471336NMedicaid