Provider Demographics
NPI:1457306300
Name:HOUDERSHELDT, RICKY L (MD)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:L
Last Name:HOUDERSHELDT
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 1:3705 TEAYS VALLEY RD
Mailing Address - Street 2:STE 202
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-8757
Mailing Address - Country:US
Mailing Address - Phone:304-757-6990
Mailing Address - Fax:304-757-0912
Practice Address - Street 1:3705 TEAYS VALLEY RD
Practice Address - Street 2:STE 202
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-8757
Practice Address - Country:US
Practice Address - Phone:304-757-6990
Practice Address - Fax:304-757-0912
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV789207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
001720446OtherBC
WV0084490000Medicaid
WV0546842Medicare ID - Type Unspecified
001720446OtherBC