Provider Demographics
NPI:1104434588
Name:BRIDGES, DEJUAN DEMETRIUS
Entity type:Individual
Prefix:
First Name:DEJUAN
Middle Name:DEMETRIUS
Last Name:BRIDGES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4614 PROSPECT AVE STE 323
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-4377
Mailing Address - Country:US
Mailing Address - Phone:216-507-7390
Mailing Address - Fax:
Practice Address - Street 1:4614 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-4394
Practice Address - Country:US
Practice Address - Phone:216-507-7390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator