Provider Demographics
NPI:1184130916
Name:DICKS, MANUEL GERVASIO RUIZ JR
Entity type:Individual
Prefix:
First Name:MANUEL GERVASIO
Middle Name:RUIZ
Last Name:DICKS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6428 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-2813
Mailing Address - Country:US
Mailing Address - Phone:904-475-2039
Mailing Address - Fax:904-330-0668
Practice Address - Street 1:6428 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-2813
Practice Address - Country:US
Practice Address - Phone:904-475-2039
Practice Address - Fax:904-330-0668
Is Sole Proprietor?:No
Enumeration Date:2017-12-15
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3226112363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily