Basic Information
| Provider Information | |||||||||
| NPI: | 1649279498 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIDDIFORD | ||||||||
| FirstName: | TERRI | ||||||||
| MiddleName: | LEA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9505 CUTLERS TRCE | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454589161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373962880 | ||||||||
| FaxNumber: | 9373952205 | ||||||||
| Practice Location | |||||||||
| Address1: | 8701 OLD TROY PIKE | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | HUBER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454241066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373962880 | ||||||||
| FaxNumber: | 9373962205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35064414 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0928401 | 05 | OH | MEDICAID | 000000560895 | 01 | BCBS OHIO | OTHER | 4208215 | 01 | OH | AETNA | OTHER |