Provider Demographics
NPI:1609808773
Name:BRIDGES, VESTINIA MADONNA (MD)
Entity Type:Individual
Prefix:DR
First Name:VESTINIA
Middle Name:MADONNA
Last Name:BRIDGES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VESTINIA
Other - Middle Name:MADONNA
Other - Last Name:POLK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8926 WOODYARD ROAD
Mailing Address - Street 2:SUITE 701
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735
Mailing Address - Country:US
Mailing Address - Phone:301-856-1682
Mailing Address - Fax:301-856-0964
Practice Address - Street 1:8926 WOODYARD ROAD
Practice Address - Street 2:SUITE 701
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735
Practice Address - Country:US
Practice Address - Phone:301-856-1682
Practice Address - Fax:301-856-0964
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0052474207X00000X, 207XX0005X
VA0101231874207X00000X, 207XX0005X
DCMD30799207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00109905OtherMEDICARE RAILROAD PTAN #
DC46950011OtherBCBS NCA PROVIDER#
DC46950011OtherBCBS NCA PROVIDER#
DC176608Medicare ID - Type UnspecifiedMETRO MEDICARE GRP PROV#
CI2264Medicare PIN
0254450001Medicare NSC
MD462*LMedicare ID - Type UnspecifiedMARYLAND MEDICARE GRP #
52 1054342OtherTAX ID NUMBER
DC46950011OtherBCBS NCA PROVIDER#
H43852Medicare UPIN