Provider Demographics
NPI:1326131681
Name:RICKETTS, RICHARD RANDALL (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:RANDALL
Last Name:RICKETTS
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 1:3287 ALTON RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-4305
Mailing Address - Country:US
Mailing Address - Phone:770-452-8817
Mailing Address - Fax:
Practice Address - Street 1:1975 CENTURY BLVD NE
Practice Address - Street 2:SUITE 6
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3316
Practice Address - Country:US
Practice Address - Phone:404-982-9938
Practice Address - Fax:404-982-9136
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0215802086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery