Provider Demographics
NPI:1114546892
Name:FICKE, ROBERT DEAN (IDC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DEAN
Last Name:FICKE
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1281 9TH AVE UNIT 1714
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-4661
Mailing Address - Country:US
Mailing Address - Phone:207-475-5303
Mailing Address - Fax:
Practice Address - Street 1:1281 9TH AVE UNIT 1714
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-4661
Practice Address - Country:US
Practice Address - Phone:207-475-5303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman