Basic Information
| Provider Information | |||||||||
| NPI: | 1285608430 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRIDGES | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14051 ST FRANCIS BLVD | ||||||||
| Address2: | SUITE 2211 | ||||||||
| City: | MIDLOTHIAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231143201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8043787443 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14051 ST FRANCIS BLVD | ||||||||
| Address2: | SUITE 2211 | ||||||||
| City: | MIDLOTHIAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231143201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8043787443 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 03/18/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 0101233287 | VA | Y | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | M8555 | TX | N | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 8BD691 | 01 | TX | BCBSTX | OTHER | 194208801 | 05 | TX | MEDICAID |