Provider Demographics
NPI:1023160686
Name:RIDILLA, JOSEPH JOHN (DO)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:JOHN
Last Name:RIDILLA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:476 E NORTHAMPTON ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-6329
Mailing Address - Country:US
Mailing Address - Phone:570-825-4460
Mailing Address - Fax:570-825-6140
Practice Address - Street 1:476 E NORTHAMPTON ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-6329
Practice Address - Country:US
Practice Address - Phone:570-825-4460
Practice Address - Fax:570-825-6140
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007440L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF99792Medicare UPIN
PA628465Medicare ID - Type Unspecified