Provider Demographics
NPI:1003823550
Name:RIDDLE, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:RIDDLE
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 1:869 W LACEY BLVD
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-4328
Mailing Address - Country:US
Mailing Address - Phone:559-582-9313
Mailing Address - Fax:559-582-2570
Practice Address - Street 1:869 W LACEY BLVD
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-4328
Practice Address - Country:US
Practice Address - Phone:559-582-9313
Practice Address - Fax:559-582-2570
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44838207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A448380Medicaid
ZZZ28687ZMedicare PIN
B65644Medicare UPIN
ZZZ28687ZMedicare ID - Type Unspecified