Provider Demographics
NPI:1023247145
Name:BRIDWELL, MITRA H (R, MR)
Entity type:Individual
Prefix:
First Name:MITRA
Middle Name:H
Last Name:BRIDWELL
Suffix:
Gender:F
Credentials:R, MR
Other - Prefix:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:107 MARYSA DR
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35811-8770
Mailing Address - Country:US
Mailing Address - Phone:256-683-2171
Mailing Address - Fax:
Practice Address - Street 1:1201 13TH AVE SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-4300
Practice Address - Country:US
Practice Address - Phone:256-350-7779
Practice Address - Fax:256-350-2272
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL2909892471M1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance Imaging