Provider Demographics
NPI:1619078649
Name:BRIDGES, MARK JOSEPH (LDO)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:JOSEPH
Last Name:BRIDGES
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-3019
Mailing Address - Country:US
Mailing Address - Phone:863-682-3226
Mailing Address - Fax:863-682-1742
Practice Address - Street 1:1600 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3019
Practice Address - Country:US
Practice Address - Phone:863-682-3226
Practice Address - Fax:863-682-1742
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1564156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD2069OtherBCBS
FLD2069OtherBCBS