Provider Demographics
NPI:1740307016
Name:RICCIARDI, DEBRA L (DO)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:L
Last Name:RICCIARDI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5080 SPECTRUM DR
Mailing Address - Street 2:SUITE 1200W
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4648
Mailing Address - Country:US
Mailing Address - Phone:972-364-8000
Mailing Address - Fax:
Practice Address - Street 1:544A W DUNDEE RD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-2675
Practice Address - Country:US
Practice Address - Phone:615-778-4066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0951102083P0500X
IL036095110207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL1742Medicare PIN
ILIL1742016Medicare UPIN