Provider Demographics
NPI:1932420809
Name:PROVOST, BRIDGETTE CIAN (MD)
Entity Type:Individual
Prefix:
First Name:BRIDGETTE
Middle Name:CIAN
Last Name:PROVOST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3708 MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-2025
Mailing Address - Country:US
Mailing Address - Phone:410-255-1600
Mailing Address - Fax:
Practice Address - Street 1:7137 ARLINGTON RD
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-2908
Practice Address - Country:US
Practice Address - Phone:240-744-3390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-15
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD0075663207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD066116300Medicaid