Provider Demographics
NPI:1740285881
Name:BRIDGFORTH, WILLIAM A (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
Last Name:BRIDGFORTH
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 1:301 MED TECH PKWY
Mailing Address - Street 2:STE. 180
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2364
Mailing Address - Country:US
Mailing Address - Phone:423-794-5540
Mailing Address - Fax:423-926-3187
Practice Address - Street 1:301 MED TECH PKWY
Practice Address - Street 2:STE. 180
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2364
Practice Address - Country:US
Practice Address - Phone:423-794-5540
Practice Address - Fax:423-926-3187
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28470208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3165014Medicare ID - Type Unspecified
TNF60304Medicare UPIN