Provider Demographics
NPI:1679530703
Name:RIDLEY, DERRICK E (MD)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:E
Last Name:RIDLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 COLISEUM DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-5906
Mailing Address - Country:US
Mailing Address - Phone:757-827-2200
Mailing Address - Fax:757-827-2266
Practice Address - Street 1:4000 COLISEUM DR
Practice Address - Street 2:SUITE 100
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5906
Practice Address - Country:US
Practice Address - Phone:757-827-2200
Practice Address - Fax:757-827-2266
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033473174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006071147Medicaid
VA006071147Medicaid
00X6028H01Medicare PIN
VAA80596Medicare UPIN