Provider Demographics
NPI:1225076359
Name:RIEDERER, MARK FREDERICK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:FREDERICK
Last Name:RIEDERER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 WAKARA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108
Mailing Address - Country:US
Mailing Address - Phone:801-587-7109
Mailing Address - Fax:
Practice Address - Street 1:590 WAKARA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108
Practice Address - Country:US
Practice Address - Phone:801-587-7109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2025-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083195207X00000X, 2080S0010X, 208000000X
TN43020208000000X
PAMD4624842080S0012X
UT13944824-1205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
No2080S0012XAllopathic & Osteopathic PhysiciansPediatricsSleep Medicine