Basic Information
Provider Information | |||||||||
NPI: | 1760793350 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RIDEOUT | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: | ERIC | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6854 TWIN LAKES AVE | ||||||||
Address2: |   | ||||||||
City: | OTTAWA | ||||||||
State: | ON | ||||||||
PostalCode: | K4P 1P1 | ||||||||
CountryCode: | CA | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 200 TRENT DRIVE | ||||||||
Address2: | DUKE UNIVERSITY MEDICAL CENTER BUILDING CR2 ROOM 0584 | ||||||||
City: | DURHAM | ||||||||
State: | NC | ||||||||
PostalCode: | 27702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9196846726 | ||||||||
FaxNumber: | 9196846002 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/29/2010 | ||||||||
LastUpdateDate: | 05/18/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   | NC | Y |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.