Provider Demographics
NPI:1891792784
Name:HUDDLESTON, RICHARD C (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
Last Name:HUDDLESTON
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 1:300 STONECREST BLVD
Mailing Address - Street 2:STE490
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167
Mailing Address - Country:US
Mailing Address - Phone:615-223-0200
Mailing Address - Fax:615-223-8704
Practice Address - Street 1:300 STONECREST BLVD
Practice Address - Street 2:STE490
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-5688
Practice Address - Country:US
Practice Address - Phone:615-223-0200
Practice Address - Fax:615-223-8704
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2007-08-08
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-20
Provider Licenses
StateLicense IDTaxonomies
TN26462207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3089841Medicaid
TN3728880Medicaid
TNB23620Medicare UPIN
TN3728880Medicare ID - Type UnspecifiedGROUP PRICING NUMBER
TN3728880Medicaid