Provider Demographics
NPI:1114339447
Name:RIDDER, KAITLIN (MD)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:RIDDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 GLEN MEADE RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6024
Mailing Address - Country:US
Mailing Address - Phone:910-763-6251
Mailing Address - Fax:910-762-7408
Practice Address - Street 1:1905 GLEN MEADE RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6024
Practice Address - Country:US
Practice Address - Phone:910-763-6251
Practice Address - Fax:910-763-7408
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0087688208800000X
NC2022-00246208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2022-00246OtherNC MEDICAL BOARD