Provider Demographics
NPI:1073031712
Name:BALDRIDGE, ETHAN P (RD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:P
Last Name:BALDRIDGE
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SHACKLEFORD WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-3886
Mailing Address - Country:US
Mailing Address - Phone:501-978-3780
Mailing Address - Fax:
Practice Address - Street 1:7 SHACKLEFORD BLVD W
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-3886
Practice Address - Country:US
Practice Address - Phone:501-664-5860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-01
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1699133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered