Provider Demographics
NPI:1316503246
Name:BALDRIDGE, OCTAVIA (RD)
Entity type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:
Last Name:BALDRIDGE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 N UNIVERSITY AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-2936
Mailing Address - Country:US
Mailing Address - Phone:501-664-4810
Mailing Address - Fax:501-663-1256
Practice Address - Street 1:701 N UNIVERSITY AVE STE 100
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-2936
Practice Address - Country:US
Practice Address - Phone:501-664-4810
Practice Address - Fax:501-663-1256
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1699133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered