Provider Demographics
NPI:1194347526
Name:RIDDLE, DUSTIN IAN SR (PTA)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:IAN
Last Name:RIDDLE
Suffix:SR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 MEADOWLARK CT
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-3142
Mailing Address - Country:US
Mailing Address - Phone:954-589-7217
Mailing Address - Fax:
Practice Address - Street 1:1000 W BROADWAY ST STE 214
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9262
Practice Address - Country:US
Practice Address - Phone:407-359-5693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty