Provider Demographics
NPI:1720200918
Name:BRIDGEMAN, JAY T (MD, DDS)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:T
Last Name:BRIDGEMAN
Suffix:
Gender:
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 S KEENE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-7199
Mailing Address - Country:US
Mailing Address - Phone:573-443-2402
Mailing Address - Fax:
Practice Address - Street 1:1 S KEENE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-7199
Practice Address - Country:US
Practice Address - Phone:573-443-2402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013000138207XS0106X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO148380072OtherMEDICARE PTAN