Provider Demographics
NPI:1760580054
Name:RIDEOUT, DAVID T (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:T
Last Name:RIDEOUT
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:PO BOX 511644
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33951-1644
Mailing Address - Country:US
Mailing Address - Phone:207-240-3362
Mailing Address - Fax:
Practice Address - Street 1:3050 CHAMPION RING RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-5599
Practice Address - Country:US
Practice Address - Phone:207-240-3362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME129811208600000X
CAG87354208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102202300Medicaid
CA00G873540Medicaid
00G873540Medicare ID - Type Unspecified