Provider Demographics
NPI:1497966808
Name:RIDDELL, CARL MICHAEL (MD, FACOG)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:MICHAEL
Last Name:RIDDELL
Suffix:
Gender:M
Credentials:MD, FACOG
Other - Prefix:DR
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:RIDDELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5800 W 10TH ST
Mailing Address - Street 2:STE.401
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-1752
Mailing Address - Country:US
Mailing Address - Phone:501-661-2480
Mailing Address - Fax:501-661-2464
Practice Address - Street 1:5800 W 10TH ST
Practice Address - Street 2:STE.401
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-1752
Practice Address - Country:US
Practice Address - Phone:501-661-2480
Practice Address - Fax:501-661-2464
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-5991207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR110831001Medicaid
AR110831001Medicaid
AR54371Medicare ID - Type Unspecified