Provider Demographics
NPI:1700118890
Name:BRIDWELL, RICHARD BRENT (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:BRENT
Last Name:BRIDWELL
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 1:1125 RAINTREE CIR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-4900
Mailing Address - Country:US
Mailing Address - Phone:972-727-9995
Mailing Address - Fax:972-727-8350
Practice Address - Street 1:1125 RAINTREE CIR
Practice Address - Street 2:SUITE 100
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-4900
Practice Address - Country:US
Practice Address - Phone:972-727-9995
Practice Address - Fax:972-727-8350
Is Sole Proprietor?:No
Enumeration Date:2010-02-01
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL32336207Q00000X
SC32336207QS0010X
TXQ0418207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine