Provider Demographics
NPI:1730159732
Name:BONGAARD, BRIDGET STINE (MD)
Entity type:Individual
Prefix:MRS
First Name:BRIDGET
Middle Name:STINE
Last Name:BONGAARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602344
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2344
Mailing Address - Country:US
Mailing Address - Phone:704-403-7050
Mailing Address - Fax:704-403-7059
Practice Address - Street 1:707 MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2975
Practice Address - Country:US
Practice Address - Phone:704-403-7050
Practice Address - Fax:704-403-7059
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28133207R00000X, 175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1730159732Medicaid
NC8102223OtherMAMSI
NC177664OtherWELLPATH
NC11176OtherPARTNERS MEDICARE CHOICE
NC1205616OtherUNITED HEALTHCARE
NC1639733OtherCIGNA HEALTHCARE
NC16783OtherBCBSNC
NC4102703OtherAETNA
NC8916783Medicaid
NC203598KOtherMEDICARE PTAN
NCA9136OtherMEDCOST
NC8916783Medicaid
NC11176OtherPARTNERS MEDICARE CHOICE