Provider Demographics
NPI:1972755072
Name:RIDAD, MARIO P
Entity type:Individual
Prefix:MR
First Name:MARIO
Middle Name:P
Last Name:RIDAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3336 LEXINGTON DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-6636
Mailing Address - Country:US
Mailing Address - Phone:903-566-1233
Mailing Address - Fax:
Practice Address - Street 1:3301 W PARK ROW BLVD
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-4846
Practice Address - Country:US
Practice Address - Phone:903-874-5238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2052710225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant