Healthcare Provider Details

I. General information

NPI: 1083604326
Provider Name (Legal Business Name): BRIDGET DAUPHIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 10/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6095 PROFESSIONAL PKWY SUITE 100
DOUGLASVILLE GA
30134-5607
US

IV. Provider business mailing address

6095 PROFESSIONAL PKWY SUITE 100
DOUGLASVILLE GA
30134-5607
US

V. Phone/Fax

Practice location:
  • Phone: 770-920-2255
  • Fax: 770-920-9963
Mailing address:
  • Phone: 770-920-2255
  • Fax: 770-920-9963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number055199
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: