Provider Demographics
NPI:1144267089
Name:RIDGE, GARY R (DPM)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:R
Last Name:RIDGE
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 1:157 N 400 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-1909
Mailing Address - Country:US
Mailing Address - Phone:801-226-2421
Mailing Address - Fax:801-226-3869
Practice Address - Street 1:157 N 400 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-1909
Practice Address - Country:US
Practice Address - Phone:801-226-2421
Practice Address - Fax:801-226-3869
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1034600501213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT270510OtherALTIUS HEALTH PLANS
UT19925OtherDESERET MUTUAL
UT2365OtherPUBLIC EMPLOYEES HEALTH
UT0761150001OtherCIGNA MEDICARE
UT107006243102OtherSELECT HEALTH
UTE0110Medicaid
UT0761150001OtherCIGNA MEDICARE