Provider Demographics
NPI:1558364083
Name:WILLIAMS, RICKEY LYNN (MD)
Entity Type:Individual
Prefix:
First Name:RICKEY
Middle Name:LYNN
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7265 E TANQUE VERDE RD
Mailing Address - Street 2:STE 121
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-3467
Mailing Address - Country:US
Mailing Address - Phone:520-722-2585
Mailing Address - Fax:520-722-1097
Practice Address - Street 1:7265 E TANQUE VERDE RD
Practice Address - Street 2:STE 121
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3467
Practice Address - Country:US
Practice Address - Phone:520-722-2585
Practice Address - Fax:520-722-1097
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ14264208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ238164-02Medicaid
AZ238164-02Medicaid