Provider Demographics
NPI:1790160364
Name:RIDER, MITCHELL PAUL (DPM)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:PAUL
Last Name:RIDER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:NAVAL HOSPITAL CMP LJN PDTRY
Mailing Address - Street 2:100 BREWSTER BLVD
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547
Mailing Address - Country:US
Mailing Address - Phone:910-450-3785
Mailing Address - Fax:
Practice Address - Street 1:BLDG 20 MEMORIAL AVE
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:TN
Practice Address - Zip Code:37684-4000
Practice Address - Country:US
Practice Address - Phone:423-926-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM0000000778213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist