Basic Information
| Provider Information | |||||||||
| NPI: | 1508021536 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIDDLE-JONES | ||||||||
| FirstName: | LATONYA | ||||||||
| MiddleName: | ANTOINETTE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RIDDLE | ||||||||
| OtherFirstName: | LATONYA | ||||||||
| OtherMiddleName: | ANTOINETTE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 400 MACK AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134489006 | ||||||||
| FaxNumber: | 3139667305 | ||||||||
| Practice Location | |||||||||
| Address1: | 4201 SAINT ANTOINE ST STE 6A&6B | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137454627 | ||||||||
| FaxNumber: | 3139667305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2008 | ||||||||
| LastUpdateDate: | 10/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301092759 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 4301092759 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.