Provider Demographics
NPI:1649375114
Name:BRIDGE, THEODORE ALLEN (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:ALLEN
Last Name:BRIDGE
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 1:1014 S 320TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-5344
Mailing Address - Country:US
Mailing Address - Phone:253-941-0673
Mailing Address - Fax:253-941-8109
Practice Address - Street 1:1014 S 320TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5344
Practice Address - Country:US
Practice Address - Phone:253-941-0673
Practice Address - Fax:253-941-8109
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029692208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1079177Medicaid