Provider Demographics
NPI:1750397865
Name:BRIDGES, WALTER (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:BRIDGES
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 1:1400 WALLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1708
Mailing Address - Country:US
Mailing Address - Phone:806-414-9800
Mailing Address - Fax:806-354-5689
Practice Address - Street 1:1400 S COULTER ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1786
Practice Address - Country:US
Practice Address - Phone:806-414-9800
Practice Address - Fax:806-354-5689
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6071207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100142070AMedicaid
NMF8785Medicaid
TX138671617Medicaid
TX138671613Medicaid
TX138671615Medicaid
TX138671616Medicaid
TX138671614Medicaid
TX138671617Medicaid
OK100142070AMedicaid