Provider Demographics
NPI:1578589040
Name:RIDGE, LEAH LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:LEAH
Middle Name:LYNN
Last Name:RIDGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1010 S KING ST
Mailing Address - Street 2:STE 106
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-1702
Mailing Address - Country:US
Mailing Address - Phone:808-486-7199
Mailing Address - Fax:808-486-7167
Practice Address - Street 1:1010 S KING ST
Practice Address - Street 2:STE 106
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1702
Practice Address - Country:US
Practice Address - Phone:808-486-7199
Practice Address - Fax:808-486-7167
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG757372084N0400X
HI81662084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI077703-01Medicaid
G25760Medicare UPIN
HI077703-01Medicaid