Provider Demographics
NPI:1730120163
Name:RIDDER, BRENT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:
Last Name:RIDDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23961 CALLE DE LA MAGDALENA
Mailing Address - Street 2:#115
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3616
Mailing Address - Country:US
Mailing Address - Phone:949-206-4633
Mailing Address - Fax:949-855-2314
Practice Address - Street 1:23961 CALLE DE LA MAGDALENA
Practice Address - Street 2:#115
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3616
Practice Address - Country:US
Practice Address - Phone:949-206-4633
Practice Address - Fax:949-855-2314
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80485207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH69414Medicare UPIN
CAWA80485EMedicare ID - Type Unspecified
CAP00200538Medicare ID - Type UnspecifiedRAILROAD MEDICARE
CA0996580001Medicare NSC