Provider Demographics
NPI:1710440169
Name:RICK, JONATHAN W (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:W
Last Name:RICK
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 1:1890 SUTTER ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-3259
Mailing Address - Country:US
Mailing Address - Phone:805-245-2915
Mailing Address - Fax:
Practice Address - Street 1:3105 CEDAR RAVINE RD STE 201
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-6561
Practice Address - Country:US
Practice Address - Phone:530-626-1602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-12
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA182777207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program