Provider Demographics
NPI:1366501876
Name:BRIDGES, ROBERT LOREN (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LOREN
Last Name:BRIDGES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 751
Mailing Address - Street 2:
Mailing Address - City:GIRDWOOD
Mailing Address - State:AK
Mailing Address - Zip Code:99587
Mailing Address - Country:US
Mailing Address - Phone:907-382-0952
Mailing Address - Fax:866-305-3886
Practice Address - Street 1:1751 E. GARDNER WAY
Practice Address - Street 2:SUITE B
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-357-1220
Practice Address - Fax:907-357-1222
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK40982085R0202X, 2085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDG1553Medicaid
AKMDG1551Medicaid
AKN2018OtherBLUE CROSS BLUE SHIELD
AKMDG1552Medicaid
AK4098OtherSTATE OF AK MEDICAL LICEN
AKMD5606Medicaid
AKMDG155Medicaid
AKMDG1553Medicaid
AK470001797Medicare ID - Type UnspecifiedMEDICARE RAILROAD