Provider Demographics
NPI:1790752574
Name:RIDDER, TIM R (OD)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:R
Last Name:RIDDER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:1851 N WEBB RD
Mailing Address - Street 2:ATTN FLR2
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3413
Mailing Address - Country:US
Mailing Address - Phone:316-636-2010
Mailing Address - Fax:316-858-3830
Practice Address - Street 1:2701 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502-3479
Practice Address - Country:US
Practice Address - Phone:620-663-8700
Practice Address - Fax:620-663-8713
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS13853152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100219360BMedicaid
KSP00292520OtherRAILROAD MEDICARE
KSU35296Medicare UPIN
KSP00292520OtherRAILROAD MEDICARE