Provider Demographics
NPI:1356337638
Name:RIDDLES, LAWRENCE MARSHALL (MD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:MARSHALL
Last Name:RIDDLES
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:187 POW MIA DR
Mailing Address - Street 2:
Mailing Address - City:SCOTT AFB
Mailing Address - State:IL
Mailing Address - Zip Code:62225-1750
Mailing Address - Country:US
Mailing Address - Phone:618-256-7456
Mailing Address - Fax:618-256-7479
Practice Address - Street 1:310 W LOSEY ST
Practice Address - Street 2:
Practice Address - City:SCOTT AFB
Practice Address - State:IL
Practice Address - Zip Code:62225-5250
Practice Address - Country:US
Practice Address - Phone:618-256-7456
Practice Address - Fax:618-256-7479
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-22
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
NY159883-1208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OTH000Medicare UPIN