Provider Demographics
NPI:1194231399
Name:RIDEOUT, DORTHA MAE
Entity type:Individual
Prefix:MRS
First Name:DORTHA
Middle Name:MAE
Last Name:RIDEOUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 E PASS RD APT U
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-3271
Mailing Address - Country:US
Mailing Address - Phone:228-547-7088
Mailing Address - Fax:
Practice Address - Street 1:2649 PALMER DR
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-2846
Practice Address - Country:US
Practice Address - Phone:228-731-3257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-26
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide