1366919375 NPI number — BRIDGETTE CONNORTON, OD, LLC

Table of content: (NPI 1366919375)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366919375 NPI number — BRIDGETTE CONNORTON, OD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
N/A
Provider Organization Name:
BRIDGETTE CONNORTON, OD, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1366919375
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5237 JONES CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70817-2124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-755-3937
Provider Business Mailing Address Fax Number:
225-755-2272

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5237 JONES CREEK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70817-2124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-755-3937
Provider Business Practice Location Address Fax Number:
225-755-2272
Provider Enumeration Date:
10/29/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CONNORTON
Authorized Official First Name:
BRIDGETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
225-755-3937

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2371991 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".