Provider Demographics
NPI:1932202710
Name:RIDDLE, KEVIN LEE (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEE
Last Name:RIDDLE
Suffix:
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 1:500 LINCOLN PARK BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-6404
Mailing Address - Country:US
Mailing Address - Phone:937-294-4487
Mailing Address - Fax:937-294-2255
Practice Address - Street 1:2717 MIAMISBURG-CENTERVILLE RD
Practice Address - Street 2:SUITE 211
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-3797
Practice Address - Country:US
Practice Address - Phone:937-434-6832
Practice Address - Fax:937-434-8371
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35059114207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0834342Medicaid
E76546Medicare UPIN
OH0834342Medicaid