Provider Demographics
NPI:1083613210
Name:RIDDELL, MAL S (DO)
Entity Type:Individual
Prefix:DR
First Name:MAL
Middle Name:S
Last Name:RIDDELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1263
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38902-1263
Mailing Address - Country:US
Mailing Address - Phone:662-226-6430
Mailing Address - Fax:662-226-0018
Practice Address - Street 1:1300 SUNSET DR
Practice Address - Street 2:SUITE B
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4086
Practice Address - Country:US
Practice Address - Phone:662-226-6430
Practice Address - Fax:662-226-0018
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08590207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018828Medicaid
MSB64658Medicare UPIN
MS082948704Medicare ID - Type Unspecified