Provider Demographics
NPI:1043454895
Name:RIDDELL, THOMAS CHRISTOPHER (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:CHRISTOPHER
Last Name:RIDDELL
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 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6063
Mailing Address - Fax:904-539-4091
Practice Address - Street 1:7720 US HIGHWAY 98 W STE 110
Practice Address - Street 2:
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-7231
Practice Address - Country:US
Practice Address - Phone:850-267-1603
Practice Address - Fax:850-622-3342
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME168738207RC0000X
AL34950207RI0011X
AL00000207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102IC37309OtherMEDICARE AL PTAN CMS/CAHABA