Provider Demographics
NPI:1861488017
Name:TATE, RICKY DEAN (MD)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:DEAN
Last Name:TATE
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 1:300 CARSON ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3104
Mailing Address - Country:US
Mailing Address - Phone:870-932-1198
Mailing Address - Fax:870-910-7700
Practice Address - Street 1:300 CARSON ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3104
Practice Address - Country:US
Practice Address - Phone:870-932-1198
Practice Address - Fax:870-910-7700
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2224207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR137536001Medicaid
AR5L193Medicare ID - Type UnspecifiedMEDICARE PROVIDER
AR137536001Medicaid
AR5L193Medicare PIN