Provider Demographics
NPI:1760447239
Name:RICKMAN, JOHN V
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:V
Last Name:RICKMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 237
Mailing Address - Street 2:
Mailing Address - City:SUBLIMITY
Mailing Address - State:OR
Mailing Address - Zip Code:97385-0237
Mailing Address - Country:US
Mailing Address - Phone:503-769-9181
Mailing Address - Fax:503-769-9182
Practice Address - Street 1:103 S CENTER STREET
Practice Address - Street 2:SUITE D
Practice Address - City:SUBLIMITY
Practice Address - State:OR
Practice Address - Zip Code:97385
Practice Address - Country:US
Practice Address - Phone:503-769-9181
Practice Address - Fax:503-769-9182
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1724ATI152W00000X
AZ651152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR107185Medicaid
OR1030190001Medicare NSC
OR0000PHNCFMedicare ID - Type Unspecified
OR107185Medicaid