Provider Demographics
NPI:1972617629
Name:RIDDLE, DUSTIN DAVID (DC,DPM,MHA)
Entity type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:DAVID
Last Name:RIDDLE
Suffix:
Gender:M
Credentials:DC,DPM,MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W2654 COUNTY ROAD KK
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-9468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:W2654 COUNTY ROAD KK
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-9468
Practice Address - Country:US
Practice Address - Phone:920-830-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3880-012111N00000X
WI1127-25213ES0103X
IL135000875213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38961800Medicaid
000370615Medicare ID - Type Unspecified
WI38961800Medicaid