Healthcare Provider Details

I. General information

NPI: 1649426651
Provider Name (Legal Business Name): RITZ CLYDE RAY JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2008
Last Update Date: 08/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 EXECUTIVE PARK BLVD STE 604
WINSTON SALEM NC
27103-1548
US

IV. Provider business mailing address

275 EXECUTIVE PARK BLVD STE 604
WINSTON SALEM NC
27103-1548
US

V. Phone/Fax

Practice location:
  • Phone: 336-768-3680
  • Fax: 336-768-3680
Mailing address:
  • Phone: 336-768-3680
  • Fax: 336-768-3680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number13211
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: