Healthcare Provider Details

I. General information

NPI: 1477505204
Provider Name (Legal Business Name): GARY BRIDGWATER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5898 NASHWAY RD
NISSWA MN
56468-2358
US

IV. Provider business mailing address

5898 NASHWAY RD
NISSWA MN
56468-2358
US

V. Phone/Fax

Practice location:
  • Phone: 608-334-4812
  • Fax:
Mailing address:
  • Phone: 608-334-4812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number56147
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: