Provider Demographics
NPI:1073076113
Name:RIDOUT, JEFFREY LEE
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LEE
Last Name:RIDOUT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3393 E MORENCI RD
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-5979
Mailing Address - Country:US
Mailing Address - Phone:480-415-9949
Mailing Address - Fax:
Practice Address - Street 1:3393 E MORENCI RD
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-5979
Practice Address - Country:US
Practice Address - Phone:480-415-9949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-06
Last Update Date:2019-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant