Provider Demographics
NPI:1902003569
Name:RIDDLE, CRAIG C (OD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:C
Last Name:RIDDLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 208944
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-8944
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:359 BRICK BLVD
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-6010
Practice Address - Country:US
Practice Address - Phone:732-920-1330
Practice Address - Fax:732-920-1370
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2022-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00476500152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU35527Medicare UPIN
NJRI606702Medicare ID - Type Unspecified