Provider Demographics
NPI:1679853790
Name:RIDON, RED ERICKSON DEYNATA (RPT)
Entity Type:Individual
Prefix:
First Name:RED ERICKSON
Middle Name:DEYNATA
Last Name:RIDON
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 LITCHFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-2717
Mailing Address - Country:US
Mailing Address - Phone:917-734-0336
Mailing Address - Fax:
Practice Address - Street 1:139 FULTON ST RM 502
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-2535
Practice Address - Country:US
Practice Address - Phone:212-571-2030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031387-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist