Healthcare Provider Details

I. General information

NPI: 1659396000
Provider Name (Legal Business Name): DAVID J RIDLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2854 HIGHWAY 55 STE 190
EAGAN MN
55121-1783
US

IV. Provider business mailing address

2854 HIGHWAY 55 STE 130
EAGAN MN
55121-1776
US

V. Phone/Fax

Practice location:
  • Phone: 651-644-4277
  • Fax: 651-644-4018
Mailing address:
  • Phone: 651-224-4930
  • Fax: 651-842-3391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number26149
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: