Provider Demographics
NPI:1720182876
Name:BRIDGER, LAURIE S (MD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:S
Last Name:BRIDGER
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 1:47 MARVEL ROAD
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06515
Mailing Address - Country:US
Mailing Address - Phone:203-387-6705
Mailing Address - Fax:
Practice Address - Street 1:374 GRAND AVE
Practice Address - Street 2:FAIR HAVEN COMMUNITY HEALTH CENTER
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513
Practice Address - Country:US
Practice Address - Phone:203-777-7411
Practice Address - Fax:203-777-8506
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031428207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235736Medicaid
010031428CT01OtherANTHEM BCBS
0314289734OtherCONNECTICARE
P473784OtherOXFORD
1051526OtherAETNA US HEALTH
2356526OtherCIGNA
P473784OtherOXFORD
E95422Medicare UPIN