Provider Demographics
NPI:1790707057
Name:RIDENOUR, JOHN W (DPM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:RIDENOUR
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:52 BERLIN RD
Mailing Address - Street 2:SUITE 5000
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-3574
Mailing Address - Country:US
Mailing Address - Phone:856-795-1003
Mailing Address - Fax:856-795-5994
Practice Address - Street 1:52 BERLIN RD
Practice Address - Street 2:SUITE 5000
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-3574
Practice Address - Country:US
Practice Address - Phone:856-795-1003
Practice Address - Fax:856-795-5994
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MD00118100213E00000X
PASC003575L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0879760OtherCIGNA
NJ71268OtherOPERATING ENGINEERS
PA0109018000OtherINDENPENDENCE BLUE CROSS
NJ10062OtherAMERIGROUP
NJ1135993OtherHORIZON NJ HEALTH
NJ3182002Medicaid
NJ46711OtherAETNA
NJP927643OtherOXFORD INSURANCE
0056291OtherGHI
PA0513900000OtherKEYSTONE HEALTH PLAN
16277OtherUNIVERSITY HEALTH PLAN
NJME000007500OtherAMERICHOICE
NJ10062OtherAMERIGROUP
PA0000679666Medicare NSC
NJ0879760OtherCIGNA
480010994Medicare ID - Type UnspecifiedRAILROAD MEDICARE
PA0109018000OtherINDENPENDENCE BLUE CROSS