Provider Demographics
NPI:1750888079
Name:O'CONNELL-LONG, BRIDGET ROSE
Entity type:Individual
Prefix:
First Name:BRIDGET
Middle Name:ROSE
Last Name:O'CONNELL-LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 E BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-6551
Mailing Address - Country:US
Mailing Address - Phone:602-243-7277
Mailing Address - Fax:
Practice Address - Street 1:635 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6551
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ63363208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics