Basic Information
| Provider Information | |||||||||
| NPI: | 1609808773 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRIDGES | ||||||||
| FirstName: | VESTINIA | ||||||||
| MiddleName: | MADONNA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | POLK | ||||||||
| OtherFirstName: | VESTINIA | ||||||||
| OtherMiddleName: | MADONNA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8926 WOODYARD ROAD | ||||||||
| Address2: | SUITE 701 | ||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018561682 | ||||||||
| FaxNumber: | 3018560964 | ||||||||
| Practice Location | |||||||||
| Address1: | 8926 WOODYARD ROAD | ||||||||
| Address2: | SUITE 701 | ||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018561682 | ||||||||
| FaxNumber: | 3018560964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 01/28/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | D0052474 | MD | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 0101231874 | VA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | MD30799 | DC | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | 0101231874 | VA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XX0005X | D0052474 | MD | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00109905 | 01 | MEDICARE RAILROAD PTAN # | OTHER | 46950011 | 01 | DC | BCBS NCA PROVIDER# | OTHER |