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General NPI Number Information
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NPI Number | 1639807894
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Entity Type | Individual
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Provider Name | BRIDGETTE MOORE
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Gender | Female
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Dates
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Enumeration Date | 08/15/2022
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Last Update Date | 08/15/2022
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Provider Practice Location Address
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Address Line | 2717 PATRICIA LN APT A
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City | GARLAND
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State | TX
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Zip | 75041-2610
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Country | US
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Telephone | 469-550-5506
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Fax |
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Provider Business Mailing Address
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Address Line | 10233 E NORTHWEST HWY UNIT 38422
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City | DALLAS
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State | TX
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Zip | 75238-4458
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Country | US
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Telephone | 214-928-0803
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 202K00000X
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Taxonomy Name | Phlebology Physician
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License Number | 22-3000
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License Number State | TX
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