Healthcare Provider Details

I. General information

NPI: 1457341893
Provider Name (Legal Business Name): JAY RIDDLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 03/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9501 FARRELL RD SUITE GC-11
FORT BELVOIR VA
22060-5901
US

IV. Provider business mailing address

PO BOX 1327
FORT BELVOIR VA
22060-1027
US

V. Phone/Fax

Practice location:
  • Phone: 703-805-0193
  • Fax:
Mailing address:
  • Phone: 703-805-0193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number54289
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: