Provider Demographics
NPI:1174837397
Name:RICCARDO, LOUIS J (DO)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:J
Last Name:RICCARDO
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 1:975 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2147
Mailing Address - Country:US
Mailing Address - Phone:423-778-5179
Mailing Address - Fax:423-778-2108
Practice Address - Street 1:975 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2147
Practice Address - Country:US
Practice Address - Phone:423-778-5179
Practice Address - Fax:423-778-2108
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2679207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ045740Medicaid
MI0E66019OtherMEDICARE GROUP
MIZ96017103Medicare PIN
MIZ96017103Medicare UPIN
MIE66019094Medicare PIN