Provider Demographics
NPI:1912014259
Name:RICKETTS, TIMOTHY MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MARK
Last Name:RICKETTS
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 1:2010 PATTON CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35216
Mailing Address - Country:US
Mailing Address - Phone:205-822-0233
Mailing Address - Fax:205-822-0235
Practice Address - Street 1:2010 PATTON CHAPEL RD
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35216
Practice Address - Country:US
Practice Address - Phone:205-822-0233
Practice Address - Fax:205-822-0235
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13998207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051553483Medicare ID - Type Unspecified
C70353Medicare UPIN