Basic Information
| Provider Information | |||||||||
| NPI: | 1336121573 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIDDLE | ||||||||
| FirstName: | JOE | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1330 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730701330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053076630 | ||||||||
| FaxNumber: | 4053076660 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 N PORTER AVE | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730716424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053297621 | ||||||||
| FaxNumber: | 4053606315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 07/31/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 10240 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100117070A | 05 | OK | MEDICAID |