Provider Demographics
NPI:1447254099
Name:BRIDGE, JACK B (OD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:B
Last Name:BRIDGE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 MORNING SUN RD
Mailing Address - Street 2:DOCTORS PARK MEDICAL BLDG
Mailing Address - City:OXFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45056-8929
Mailing Address - Country:US
Mailing Address - Phone:513-523-2020
Mailing Address - Fax:513-523-1101
Practice Address - Street 1:5225 MORNING SUN RD
Practice Address - Street 2:SUITE B
Practice Address - City:OXFORD
Practice Address - State:OH
Practice Address - Zip Code:45056-8929
Practice Address - Country:US
Practice Address - Phone:513-523-2020
Practice Address - Fax:513-523-1101
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3062T1243152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBR0405631Medicare ID - Type Unspecified
OHT146686Medicare UPIN