Provider Demographics
NPI:1730281841
Name:RIBAUDO, STEPHEN RALPH (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:RALPH
Last Name:RIBAUDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:STEPHEN
Other - Middle Name:RALPH
Other - Last Name:RIBAUDO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:229 RED COACH DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3195
Mailing Address - Country:US
Mailing Address - Phone:574-252-5852
Mailing Address - Fax:574-252-5862
Practice Address - Street 1:229 RED COACH DR
Practice Address - Street 2:SUITE 102
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3195
Practice Address - Country:US
Practice Address - Phone:574-252-5852
Practice Address - Fax:574-252-5862
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034333208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN250000701OtherMEDICARE RAILROAD
IN100090100AMedicaid