Provider Demographics
NPI:1922170950
Name:RICKERT, DOUGLAS G (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:G
Last Name:RICKERT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 WESTERN AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:GUILDERLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12084-9563
Mailing Address - Country:US
Mailing Address - Phone:518-456-6000
Mailing Address - Fax:
Practice Address - Street 1:2050 WESTERN AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:GUILDERLAND
Practice Address - State:NY
Practice Address - Zip Code:12084-9563
Practice Address - Country:US
Practice Address - Phone:518-456-6000
Practice Address - Fax:518-456-3426
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV 3390-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1159490001Medicare NSC