Provider Demographics
NPI:1265427504
Name:RIDOUT, DANIEL LYMAN III (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:LYMAN
Last Name:RIDOUT
Suffix:III
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 1:350 W COUNTRY CLUB RD
Mailing Address - Street 2:SUITE #105
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5205
Mailing Address - Country:US
Mailing Address - Phone:575-624-4651
Mailing Address - Fax:575-624-4875
Practice Address - Street 1:350 W COUNTRY CLUB RD
Practice Address - Street 2:SUITE #105
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5205
Practice Address - Country:US
Practice Address - Phone:575-624-4651
Practice Address - Fax:575-624-4875
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237677207RG0100X
NMMD2015-0106207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNPI & TINOtherBLUE CROSS BLUE SHIELD OF NM
NMNPI & TINOtherBLUE CROSS BLUE SHIELD OF NM
VA1265427504Medicaid
VAP01090277Medicare PIN