Provider Demographics
NPI:1740361336
Name:BRIDGHAM, JERRY ALAN (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:ALAN
Last Name:BRIDGHAM
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:PO BOX 44004
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4004
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-268-9708
Practice Address - Street 1:14810 OLD SAINT AUGUSTINE RD STE 106
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-2558
Practice Address - Country:US
Practice Address - Phone:904-268-7701
Practice Address - Fax:904-268-9708
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME493972080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3747107-00Medicaid
E60463Medicare UPIN
11223Medicare ID - Type Unspecified