Provider Demographics
NPI:1043398456
Name:RIDDLE, GREGORY ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALLEN
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 1:5202 TEXANA DR
Mailing Address - Street 2:APT 835
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-3772
Mailing Address - Country:US
Mailing Address - Phone:256-617-0228
Mailing Address - Fax:
Practice Address - Street 1:1515 TRUEMPER ST
Practice Address - Street 2:
Practice Address - City:LACKLAND A F B
Practice Address - State:TX
Practice Address - Zip Code:78236-5583
Practice Address - Country:US
Practice Address - Phone:210-292-7027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19406207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine