Provider Demographics
NPI:1568468692
Name:RIDILLA, LEONARD V (MD)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:V
Last Name:RIDILLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 E REDMAN AVE
Mailing Address - Street 2:
Mailing Address - City:HADDONFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08033-2316
Mailing Address - Country:US
Mailing Address - Phone:856-428-1335
Mailing Address - Fax:856-428-6334
Practice Address - Street 1:15 E REDMAN AVE
Practice Address - Street 2:
Practice Address - City:HADDONFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08033-2316
Practice Address - Country:US
Practice Address - Phone:856-428-1335
Practice Address - Fax:856-428-6334
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA05731800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC53942Medicare UPIN