Provider Demographics
NPI:1215089974
Name:RIDDLE, JEFFERSON EUGENE
Entity type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:EUGENE
Last Name:RIDDLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 FOUNTAIN VIEW DR STE 200
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-4832
Mailing Address - Country:US
Mailing Address - Phone:713-620-4000
Mailing Address - Fax:
Practice Address - Street 1:2411 FOUNTAIN VIEW DR
Practice Address - Street 2:SUITE 200
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-4817
Practice Address - Country:US
Practice Address - Phone:713-458-4185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5536207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX125599402Medicaid
LA1476200OtherLA - MEDICAID
TX8014J5OtherOUT HARRIS - MEDICARE
84Y576OtherTX-BLUE SHIELD
TX125599402Medicaid
84Y576OtherTX-BLUE SHIELD
050041702Medicare PIN