Provider Demographics
NPI:1811332992
Name:BRIDGE, GARETH S
Entity type:Individual
Prefix:DR
First Name:GARETH
Middle Name:S
Last Name:BRIDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S DERBY ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SUBLETTE
Mailing Address - State:KS
Mailing Address - Zip Code:67877-6704
Mailing Address - Country:US
Mailing Address - Phone:620-675-2686
Mailing Address - Fax:620-675-2236
Practice Address - Street 1:301 S DERBY ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SUBLETTE
Practice Address - State:KS
Practice Address - Zip Code:67877-6704
Practice Address - Country:US
Practice Address - Phone:620-675-2686
Practice Address - Fax:620-675-2236
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-39010207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine