Provider Demographics
NPI:1871588277
Name:RIDEN, DAVID J (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:RIDEN
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 1:805 SANDY PLAINS ROAD
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3747 ROSWELL RD STE 201
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062
Practice Address - Country:US
Practice Address - Phone:770-578-2868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA399162088P0231X
TN312402088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3841062Medicaid
TNF33766Medicare UPIN
TN3841064Medicare ID - Type Unspecified