Provider Demographics
NPI:1093032880
Name:BRIDGES, MISTY M (OM)
Entity type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:M
Last Name:BRIDGES
Suffix:
Gender:F
Credentials:OM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 E HERITAGE DR STE 5E
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-5112
Mailing Address - Country:US
Mailing Address - Phone:903-245-8667
Mailing Address - Fax:903-595-4639
Practice Address - Street 1:106 E HERITAGE DR STE 5E
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5112
Practice Address - Country:US
Practice Address - Phone:903-245-8667
Practice Address - Fax:903-595-4639
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-03
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7882174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist