Provider Demographics
NPI:1316989304
Name:RIDDLE, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:RIDDLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1111 N CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-5505
Mailing Address - Country:US
Mailing Address - Phone:410-837-2050
Mailing Address - Fax:866-629-0091
Practice Address - Street 1:5500 KNOLL NORTH DR STE 370
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2393
Practice Address - Country:US
Practice Address - Phone:410-837-2050
Practice Address - Fax:866-629-0091
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD00456962084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD162501200Medicaid
MDH897JOMedicare ID - Type Unspecified
MDE89926Medicare UPIN
MDLG74Medicare ID - Type Unspecified
MDK320JOMedicare ID - Type Unspecified
MD162501200Medicaid