Provider Demographics
NPI:1942223839
Name:RIDDLE, GARY D (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:D
Last Name:RIDDLE
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 1:100 ST MARYS EPWORTH XING # B100
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-9497
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 ST MARYS EPWORTH XING # B100
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-9497
Practice Address - Country:US
Practice Address - Phone:812-469-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ01043786207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN080112157OtherRAILROAD MEDICARE
IN100369570Medicaid
IN080112157OtherRAILROAD MEDICARE
IN100369570Medicaid
IN192680BMedicare PIN