Provider Demographics
NPI:1821018763
Name:RICKERSON, AVERESS DEAN (MD)
Entity Type:Individual
Prefix:
First Name:AVERESS
Middle Name:DEAN
Last Name:RICKERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:A
Other - Middle Name:VICKI
Other - Last Name:RICKERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:8601 VILLAGE DR
Mailing Address - Street 2:100
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-5509
Mailing Address - Country:US
Mailing Address - Phone:210-646-7227
Mailing Address - Fax:210-654-3575
Practice Address - Street 1:8601 VILLAGE DR
Practice Address - Street 2:100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-5509
Practice Address - Country:US
Practice Address - Phone:210-646-7227
Practice Address - Fax:210-654-3575
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7575207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX031773001Medicaid
B25908Medicare UPIN
TX00A86BMedicare PIN