Provider Demographics
NPI:1205840618
Name:RICCIARDI, MICHAEL T (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:RICCIARDI
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 1:1224 TENTH ST
Mailing Address - Street 2:# 200
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118
Mailing Address - Country:US
Mailing Address - Phone:619-435-6902
Mailing Address - Fax:619-435-6996
Practice Address - Street 1:1224 TENTH ST
Practice Address - Street 2:# 200
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118
Practice Address - Country:US
Practice Address - Phone:619-435-6902
Practice Address - Fax:619-435-6996
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A60182084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABR6055467OtherDEA
CABR6055467OtherDEA