Provider Demographics
NPI:1023192234
Name:RICKETTS, RANDALL VINCENT (DO)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:VINCENT
Last Name:RICKETTS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26991 CROWN VALLEY PKWY
Mailing Address - Street 2:# 100
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6528
Mailing Address - Country:US
Mailing Address - Phone:949-923-3277
Mailing Address - Fax:855-812-5865
Practice Address - Street 1:26991 CROWN VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6528
Practice Address - Country:US
Practice Address - Phone:949-582-5430
Practice Address - Fax:949-348-9513
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4956207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX49560OtherMEDICAL
CA00AX49560OtherMEDICAL
CAA93601Medicare UPIN