Provider Demographics
NPI:1609133362
Name:BRIDGES, MARY GRACE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY GRACE
Middle Name:
Last Name:BRIDGES
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 1:601 N TOM GREEN AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4525
Mailing Address - Country:US
Mailing Address - Phone:432-332-0090
Mailing Address - Fax:833-908-2112
Practice Address - Street 1:601 N TOM GREEN AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4525
Practice Address - Country:US
Practice Address - Phone:432-332-0090
Practice Address - Fax:833-908-2112
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ7016207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX356781001Medicaid
TX356781002Medicaid
NM93505264Medicaid
OK200654770 AMedicaid
TX356781001Medicaid