Healthcare Provider Details

I. General information

NPI: 1730120163
Provider Name (Legal Business Name): BRENT RIDDER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23961 CALLE DE LA MAGDALENA #115
LAGUNA HILLS CA
92653-3616
US

IV. Provider business mailing address

23961 CALLE DE LA MAGDALENA #115
LAGUNA HILLS CA
92653-3616
US

V. Phone/Fax

Practice location:
  • Phone: 949-206-4633
  • Fax: 949-855-2314
Mailing address:
  • Phone: 949-206-4633
  • Fax: 949-855-2314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA80485
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: