Provider Demographics
NPI:1114905445
Name:RICKE, BRUCE LAWRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:LAWRENCE
Last Name:RICKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7800 SW 57TH AVE
Mailing Address - Street 2:STE 225E
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-5528
Mailing Address - Country:US
Mailing Address - Phone:305-665-3990
Mailing Address - Fax:
Practice Address - Street 1:7800 SW 57TH AVE
Practice Address - Street 2:STE 225E
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-5528
Practice Address - Country:US
Practice Address - Phone:305-665-3990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 459072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL044909100Medicaid
FLD50574Medicare UPIN
FL02598Medicare ID - Type Unspecified