MEDICARE: DR. BRIDGET I FATH O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT.006182	OH
2	152W00000X	Optometrist	18002418	IN

General Provider Information

NPI Number	:	1245224476
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIDGET I FATH O.D.

Provider Business Mailing Address
First Line	:	PO BOX 207170
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75320-7170
Country	:	US
Telephone Number	:	636-200-4393
Fax Number	:	636-527-0766

Provider Business Practice Location Address
First Line	:	238 BROOKLEY AVE
Second Line	:
City	:	BOLLING AFB
State	:	DC
Zip	:	20032
Country	:	US
Telephone Number	:	202-404-1484
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/02/2005
Last Update Date	:	09/20/2022

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