Healthcare Provider Details

I. General information

NPI: 1003920497
Provider Name (Legal Business Name): RIDGELY OLIVER MULLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 MONTGOMERY DR
SANTA ROSA CA
95405-4801
US

IV. Provider business mailing address

1165 MONTGOMERY DR
SANTA ROSA CA
95405-4801
US

V. Phone/Fax

Practice location:
  • Phone: 707-525-5207
  • Fax: 626-397-5643
Mailing address:
  • Phone: 707-303-8307
  • Fax: 818-952-1175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA64483
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: