Provider Demographics
NPI:1831120310
Name:RIDGE, LARESA (MD)
Entity Type:Individual
Prefix:
First Name:LARESA
Middle Name:
Last Name:RIDGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17330 LASSEN FOREST LN
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346-1550
Mailing Address - Country:US
Mailing Address - Phone:281-788-2615
Mailing Address - Fax:
Practice Address - Street 1:9105 N WAYSIDE DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77028-1030
Practice Address - Country:US
Practice Address - Phone:214-276-8665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7535207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8P2795OtherBCBS
TX168810301Medicaid
TX8C8322Medicare PIN
TX8P2795OtherBCBS
TXP00166026Medicare PIN