Provider Demographics
NPI:1477505204
Name:BRIDGWATER, GARY (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:BRIDGWATER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5898 NASHWAY RD
Mailing Address - Street 2:
Mailing Address - City:NISSWA
Mailing Address - State:MN
Mailing Address - Zip Code:56468-2358
Mailing Address - Country:US
Mailing Address - Phone:608-334-4812
Mailing Address - Fax:
Practice Address - Street 1:5898 NASHWAY RD
Practice Address - Street 2:
Practice Address - City:NISSWA
Practice Address - State:MN
Practice Address - Zip Code:56468-2358
Practice Address - Country:US
Practice Address - Phone:608-334-4812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN56147174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI19957OtherMEDICAL LICENSE
MN56147OtherMINNESOTA MEDICAL LICENSE
MNFB1552086OtherDEA