Provider Demographics
NPI:1093758146
Name:RIDDLE, ROBERT A (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:RIDDLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 W STODDARD ST
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841-1654
Mailing Address - Country:US
Mailing Address - Phone:573-624-7775
Mailing Address - Fax:573-624-7775
Practice Address - Street 1:203 W STODDARD ST
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MO
Practice Address - Zip Code:63841-1654
Practice Address - Country:US
Practice Address - Phone:573-624-7775
Practice Address - Fax:573-624-7775
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02532152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO509168OtherADVANTRA FREEDOM
MO312329907Medicaid
MO312329907Medicaid
MO410011017Medicare PIN
MO509168OtherADVANTRA FREEDOM
MO000007353Medicare PIN