Provider Demographics
NPI:1679074132
Name:RIDDLE, CASSANDRA LEE (DO)
Entity Type:Individual
Prefix:DR
First Name:CASSANDRA
Middle Name:LEE
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:CASSANDRA
Other - Middle Name:LEE
Other - Last Name:CZARNETZKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:6600 S YALE AVE STE 1400
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3331
Mailing Address - Country:US
Mailing Address - Phone:888-247-0125
Mailing Address - Fax:918-502-8210
Practice Address - Street 1:10505 E 91ST ST STE 203
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5829
Practice Address - Country:US
Practice Address - Phone:918-930-7312
Practice Address - Fax:918-307-3121
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6637208600000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200874640AMedicaid