Healthcare Provider Details

I. General information

NPI: 1437144870
Provider Name (Legal Business Name): KENNETH G BRIDGES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8513 S FEDERAL HWY
PORT ST LUCIE FL
34952-3346
US

IV. Provider business mailing address

9639 FAIRWOOD CT
PORT SAINT LUCIE FL
34986-3250
US

V. Phone/Fax

Practice location:
  • Phone: 772-461-7500
  • Fax:
Mailing address:
  • Phone: 772-489-0500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME69634
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: