Provider Demographics
NPI:1710986005
Name:RIDGWAY, HAL BLAKE (MD)
Entity Type:Individual
Prefix:DR
First Name:HAL
Middle Name:BLAKE
Last Name:RIDGWAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1760 N CONGRESS AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33426-8214
Mailing Address - Country:US
Mailing Address - Phone:561-733-0077
Mailing Address - Fax:561-733-0022
Practice Address - Street 1:1760 N CONGRESS AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-8214
Practice Address - Country:US
Practice Address - Phone:561-733-0077
Practice Address - Fax:561-733-0022
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0054995207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLB14924Medicare UPIN
FL14924ZMedicare ID - Type Unspecified