Provider Demographics
NPI:1982834198
Name:RICKETTS, ROBERT MODESTO (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MODESTO
Last Name:RICKETTS
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:6700 N ROCHESTER RD
Mailing Address - Street 2:STE 100
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48306-4378
Mailing Address - Country:US
Mailing Address - Phone:248-853-6300
Mailing Address - Fax:248-853-6303
Practice Address - Street 1:1701 SOUTH BLVD E
Practice Address - Street 2:SUITE 150
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-6122
Practice Address - Country:US
Practice Address - Phone:248-853-6300
Practice Address - Fax:248-853-6303
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2018-02-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5101018209207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI320035325OtherTAX ID