Provider Demographics
NPI:1568464402
Name:RICKETTS, CHRISTOPHER M (MD)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:M
Last Name:RICKETTS
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 1:1400 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46975-8931
Mailing Address - Country:US
Mailing Address - Phone:574-224-1044
Mailing Address - Fax:574-224-1103
Practice Address - Street 1:530 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:ARGOS
Practice Address - State:IN
Practice Address - Zip Code:46501-1134
Practice Address - Country:US
Practice Address - Phone:574-892-5131
Practice Address - Fax:574-892-6349
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051336207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200364510AMedicaid
194980AMedicare ID - Type Unspecified
IN200364510AMedicaid