Provider Demographics
NPI:1073507109
Name:FIKE, RICHARD (PT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:FIKE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4737 EL CAMINO AVE
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-4938
Mailing Address - Country:US
Mailing Address - Phone:916-487-3473
Mailing Address - Fax:916-487-3483
Practice Address - Street 1:4737 EL CAMINO AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-4938
Practice Address - Country:US
Practice Address - Phone:916-487-3473
Practice Address - Fax:916-487-3483
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-05
Last Update Date:2010-10-26
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
CAPT11140225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ04666ZOtherBLUESHIELD GROUP PROVIDER
CAOPT111400Medicare ID - Type UnspecifiedINDIVIDUAL ID
CAZZZ314823Medicare ID - Type UnspecifiedGROUP IDENTIFIER