Provider Demographics
NPI:1619131463
Name:AVERESS DEAN RICKERSON
Entity Type:Organization
Organization Name:AVERESS DEAN RICKERSON
Other - Org Name:A VICKI RICKERSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AVERESS
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:RICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-646-7227
Mailing Address - Street 1:8601 VILLAGE DR
Mailing Address - Street 2:100
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-5509
Mailing Address - Country:US
Mailing Address - Phone:210-646-7227
Mailing Address - Fax:210-654-3575
Practice Address - Street 1:8601 VILLAGE DR
Practice Address - Street 2:100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-5509
Practice Address - Country:US
Practice Address - Phone:210-646-7227
Practice Address - Fax:210-654-3575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7575207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX031773001Medicaid
TXB25908Medicare UPIN
TX031773001Medicaid