Provider Demographics
NPI:1093711871
Name:RIDDICK, ROBERT STEVEN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:STEVEN
Last Name:RIDDICK
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 1:1036C SMOKEY HOLW
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-3672
Mailing Address - Country:US
Mailing Address - Phone:541-217-0600
Mailing Address - Fax:
Practice Address - Street 1:30 7TH ST W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4335
Practice Address - Country:US
Practice Address - Phone:701-456-4387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-25
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND12077208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND545777844AMedicaid
ND12077OtherMEDICAL LICENSE
ND12077OtherMEDICAL LICENSE