Provider Demographics
NPI:1174780530
Name:RIDGELEY, JAMISON R (MD)
Entity type:Individual
Prefix:MR
First Name:JAMISON
Middle Name:R
Last Name:RIDGELEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1412 SW 43RD ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057
Mailing Address - Country:US
Mailing Address - Phone:253-236-5720
Mailing Address - Fax:425-988-0168
Practice Address - Street 1:1412 SW 43RD ST
Practice Address - Street 2:SUITE 206
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057
Practice Address - Country:US
Practice Address - Phone:253-236-5720
Practice Address - Fax:425-988-0168
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2024-11-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD60638738207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1184191603Medicaid
NC1174780530Medicaid