Provider Demographics
NPI:1144426826
Name:RIDOUT, ROBERT GLADSTONE III (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GLADSTONE
Last Name:RIDOUT
Suffix:III
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 1:2200 BERGQUIST DR STE 1
Mailing Address - Street 2:
Mailing Address - City:LACKLAND A F B
Mailing Address - State:TX
Mailing Address - Zip Code:78236-9908
Mailing Address - Country:US
Mailing Address - Phone:210-292-5282
Mailing Address - Fax:
Practice Address - Street 1:2200 BERGQUIST DR STE 1
Practice Address - Street 2:
Practice Address - City:LACKLAND A F B
Practice Address - State:TX
Practice Address - Zip Code:78236-9908
Practice Address - Country:US
Practice Address - Phone:210-292-5282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1250286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital