Provider Demographics
NPI:1073505004
Name:RIEDEL, DAVID ROBERT (MD)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ROBERT
Last Name:RIEDEL
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 1:4 MEMORIAL DR STE 230
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6704
Mailing Address - Country:US
Mailing Address - Phone:618-463-7874
Mailing Address - Fax:618-463-7846
Practice Address - Street 1:4 MEMORIAL DR STE 230
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6704
Practice Address - Country:US
Practice Address - Phone:618-463-7874
Practice Address - Fax:618-463-7846
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-060307207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C41011Medicare UPIN
IL649591Medicare ID - Type Unspecified