Provider Demographics
NPI:1700877537
Name:TAH-CLAYTON, BRIDGET Y (DO)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:Y
Last Name:TAH-CLAYTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-579-3025
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:701 SOUTH 28TH AVENUE
Practice Address - Street 2:SUITE D
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401
Practice Address - Country:US
Practice Address - Phone:601-579-3025
Practice Address - Fax:601-264-0727
Is Sole Proprietor?:No
Enumeration Date:2005-11-01
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16941207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122708Medicaid
MSP00445048OtherRAILROAD MEDICARE
H26312Medicare UPIN
MS00122708Medicaid