Provider Demographics
NPI:1619165925
Name:RICKERTSEN, DWAIN WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:DWAIN
Middle Name:WILLIAM
Last Name:RICKERTSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 939
Mailing Address - Street 2:
Mailing Address - City:ANGELS CAMP
Mailing Address - State:CA
Mailing Address - Zip Code:95222-0939
Mailing Address - Country:US
Mailing Address - Phone:209-754-6262
Mailing Address - Fax:209-736-1814
Practice Address - Street 1:1233 PLUMAS ST
Practice Address - Street 2:SUITE A
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-3410
Practice Address - Country:US
Practice Address - Phone:530-671-2020
Practice Address - Fax:530-671-6797
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2018-12-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA450730207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE90666Medicare UPIN