Provider Demographics
NPI:1679764757
Name:MOORE, BRIDGETT (MD)
Entity Type:Individual
Prefix:
First Name:BRIDGETT
Middle Name:
Last Name:MOORE
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 1:2810 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1716
Mailing Address - Country:US
Mailing Address - Phone:229-259-0019
Mailing Address - Fax:229-259-0209
Practice Address - Street 1:2810 N OAK ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1716
Practice Address - Country:US
Practice Address - Phone:229-259-0019
Practice Address - Fax:229-259-0209
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA39418174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA598880OtherBCBS GA PROVIDER #
GA00830277AMedicaid
GA110206439OtherMEDICARE RR PROVIDER #
GA00830277AMedicaid
GA24BCBRCMedicare PIN