Provider Demographics
NPI:1306837075
Name:RIDENOUR, TODD (MD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:RIDENOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 E RUSHOLME ST STE 303
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2400
Mailing Address - Country:US
Mailing Address - Phone:563-383-2763
Mailing Address - Fax:563-328-5500
Practice Address - Street 1:1230 E RUSHOLME ST STE 303
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2400
Practice Address - Country:US
Practice Address - Phone:563-383-2763
Practice Address - Fax:563-328-5500
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA27062207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0088971Medicaid
IA08196OtherBCBS
IA16496Medicare ID - Type Unspecified
F28461Medicare UPIN