Provider Demographics
NPI: | 1295814408 |
---|---|
Name: | GARRISON, RIC SCOTT (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | RIC |
Middle Name: | SCOTT |
Last Name: | GARRISON |
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: | 41210 11TH ST W |
Mailing Address - Street 2: | STE C |
Mailing Address - City: | PALMDALE |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 93551-1447 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 661-947-7100 |
Mailing Address - Fax: | 661-947-1415 |
Practice Address - Street 1: | 41210 11TH ST W |
Practice Address - Street 2: | STE C |
Practice Address - City: | PALMDALE |
Practice Address - State: | CA |
Practice Address - Zip Code: | 93551-1447 |
Practice Address - Country: | US |
Practice Address - Phone: | 661-947-7100 |
Practice Address - Fax: | 661-947-1415 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-11-06 |
Last Update Date: | 2018-03-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | G50780 | 132700000X, 204C00000X, 207K00000X, 207N00000X, 207NI0002X, 207Q00000X, 207QA0000X, 207QA0401X, 207QA0505X, 207QG0300X, 207QS0010X, 207R00000X, 207V00000X, 208000000X, 208100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | |
No | 132700000X | Dietary & Nutritional Service Providers | Dietary Manager | |
No | 204C00000X | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine, Sports Medicine | |
No | 207K00000X | Allopathic & Osteopathic Physicians | Allergy & Immunology | |
No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | |
No | 207NI0002X | Allopathic & Osteopathic Physicians | Dermatology | Clinical & Laboratory Dermatological Immunology |
No | 207QA0000X | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine |
No | 207QA0401X | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
No | 207QA0505X | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
No | 207QG0300X | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
No | 207QS0010X | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | |
No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | A93004 | Medicare UPIN |