Provider Demographics
NPI:1265870778
Name:RIDDLE, MEREDITH (MD)
Entity type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:RIDDLE
Suffix:
Gender:F
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:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:4844 DEER LAKE DR W STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-4506
Practice Address - Country:US
Practice Address - Phone:904-738-8690
Practice Address - Fax:904-390-7429
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO 3690207Q00000X
FLOS 12980207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01736189OtherRR MEDICARE
FLIS970ZMedicare UPIN