Provider Demographics
NPI:1619362639
Name:RICKERT, NICHOLAS JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JOSEPH
Last Name:RICKERT
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 1:1807 W WATROUS AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-3042
Mailing Address - Country:US
Mailing Address - Phone:609-504-1245
Mailing Address - Fax:
Practice Address - Street 1:119 OAKFIELD DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5779
Practice Address - Country:US
Practice Address - Phone:813-681-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME138850207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program