Provider Demographics
NPI:1366634545
Name:DAVID J RICKLES, MD INC.
Entity Type:Organization
Organization Name:DAVID J RICKLES, MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:RICKLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-202-6474
Mailing Address - Street 1:150 N ROBERTSON BLVD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-2142
Mailing Address - Country:US
Mailing Address - Phone:310-202-4764
Mailing Address - Fax:310-202-4187
Practice Address - Street 1:3828 DELMAS TER
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2713
Practice Address - Country:US
Practice Address - Phone:310-202-4764
Practice Address - Fax:310-202-4187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56693174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC35843Medicare UPIN
CAA93450Medicare UPIN