Provider Demographics
NPI:1053337931
Name:RIEDER, JEFFREY GEORGE (DPM)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:GEORGE
Last Name:RIEDER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PECKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18452-2043
Mailing Address - Country:US
Mailing Address - Phone:570-489-5550
Mailing Address - Fax:570-489-5958
Practice Address - Street 1:1234 MAIN ST
Practice Address - Street 2:
Practice Address - City:PECKVILLE
Practice Address - State:PA
Practice Address - Zip Code:18452-2043
Practice Address - Country:US
Practice Address - Phone:570-489-5550
Practice Address - Fax:570-489-5958
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003897L213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARI758002Medicare ID - Type Unspecified
PAU48244Medicare UPIN