Provider Demographics
NPI:1790984730
Name:RICO, WILFRED M M (MD)
Entity Type:Individual
Prefix:
First Name:WILFRED
Middle Name:M M
Last Name:RICO
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 1:7000 SUNNE LANE
Mailing Address - Street 2:APT. 601
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597
Mailing Address - Country:US
Mailing Address - Phone:310-722-4480
Mailing Address - Fax:
Practice Address - Street 1:7000 SUNNE LANE
Practice Address - Street 2:APT. 601
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94597
Practice Address - Country:US
Practice Address - Phone:310-722-4480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44363207P00000X
CAA100750207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A1007501Medicare PIN