Provider Demographics
NPI:1528332780
Name:RIDDLES, MARK (BHRS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:RIDDLES
Suffix:
Gender:M
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11212 N MAY AVE
Mailing Address - Street 2:STE. 208
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-6336
Mailing Address - Country:US
Mailing Address - Phone:405-708-6331
Mailing Address - Fax:405-708-6331
Practice Address - Street 1:11212 N MAY AVE
Practice Address - Street 2:STE. 208
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-6336
Practice Address - Country:US
Practice Address - Phone:405-708-6331
Practice Address - Fax:405-708-6331
Is Sole Proprietor?:No
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200308690BMedicaid