Provider Demographics
NPI:1639519531
Name:RICKERTSEN, BRANDON BEAU (DO)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:BEAU
Last Name:RICKERTSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 W PLATT ST # 1
Mailing Address - Street 2:
Mailing Address - City:MAQUOKETA
Mailing Address - State:IA
Mailing Address - Zip Code:52060-2038
Mailing Address - Country:US
Mailing Address - Phone:563-652-5145
Mailing Address - Fax:563-652-3674
Practice Address - Street 1:918 W PLATT ST # 1
Practice Address - Street 2:
Practice Address - City:MAQUOKETA
Practice Address - State:IA
Practice Address - Zip Code:52060-2038
Practice Address - Country:US
Practice Address - Phone:563-652-5145
Practice Address - Fax:563-652-3674
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-9693207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IADO-04590OtherIA LICENSE NUMBER
IADO-04590OtherIA LICENSE NUMBER