Provider Demographics
NPI:1518987817
Name:REAVES, RICKY (MD)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:
Last Name:REAVES
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 1:3509 FRENCH PARK DR
Mailing Address - Street 2:STE D
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-7296
Mailing Address - Country:US
Mailing Address - Phone:405-715-4500
Mailing Address - Fax:
Practice Address - Street 1:3509 FRENCH PARK DR
Practice Address - Street 2:STE D
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-7296
Practice Address - Country:US
Practice Address - Phone:405-715-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16463207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
731527740OtherTAX ID/GROUP MEDICARE
OK100746640AMedicaid
OK100746640AMedicaid