Provider Demographics
NPI:1568447738
Name:RICK, CALVIN J (MD)
Entity Type:Individual
Prefix:
First Name:CALVIN
Middle Name:J
Last Name:RICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CALVIN
Other - Middle Name:J
Other - Last Name:RICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:55 W TIETAN ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4445
Mailing Address - Country:US
Mailing Address - Phone:509-525-3720
Mailing Address - Fax:509-522-1593
Practice Address - Street 1:55 W TIETAN ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4445
Practice Address - Country:US
Practice Address - Phone:509-525-3720
Practice Address - Fax:509-522-1593
Is Sole Proprietor?:No
Enumeration Date:2005-12-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028902208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2021561Medicaid
WA2021561Medicaid