Provider Demographics
NPI:1780685651
Name:JENSEN, RICKY C (MD)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:C
Last Name:JENSEN
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-4538
Mailing Address - Fax:605-328-4531
Practice Address - Street 1:1310 W 22ND ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1501
Practice Address - Country:US
Practice Address - Phone:605-328-8200
Practice Address - Fax:605-328-8201
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10034207Y00000X
SD5933207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0044540Medicaid
MT000082497Medicare ID - Type Unspecified
G45296Medicare UPIN
SDP00386563Medicare PIN
SDS101272Medicare PIN