Healthcare Provider Details

I. General information

NPI: 1003852690
Provider Name (Legal Business Name): COURTNEY PAIGE RIDLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DR. WADE CLARK RIDLEY JR.

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 CALIFORNIA ST
SAN FRANCISCO CA
94115-2753
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 415-600-3503
  • Fax: 415-600-3514
Mailing address:
  • Phone: 415-600-3503
  • Fax: 415-600-3514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License NumberA125717
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: