Provider Demographics
NPI:1427219799
Name:RIDGEWAY, ROGER DALE JR (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:DALE
Last Name:RIDGEWAY
Suffix:JR
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 1:2101 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5340
Mailing Address - Country:US
Mailing Address - Phone:228-497-7584
Mailing Address - Fax:228-497-7586
Practice Address - Street 1:4502 LT EUGENE J MAJURE DR
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-5305
Practice Address - Country:US
Practice Address - Phone:228-696-9224
Practice Address - Fax:228-696-9228
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL311302084P0800X
390200000X
MS219222084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02030025Medicaid
258515YKC0Medicare PIN