Provider Demographics
NPI:1245282011
Name:IDETA, RICK WAYNE (OD)
Entity type:Individual
Prefix:DR
First Name:RICK
Middle Name:WAYNE
Last Name:IDETA
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 1:7215 N 1ST ST
Mailing Address - Street 2:STE 101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2985
Mailing Address - Country:US
Mailing Address - Phone:559-226-3937
Mailing Address - Fax:559-226-8305
Practice Address - Street 1:7215 N 1ST ST
Practice Address - Street 2:STE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2985
Practice Address - Country:US
Practice Address - Phone:559-226-3937
Practice Address - Fax:559-226-8305
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT8503TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA191148OtherSAFEGUARD INS
CASD0085030Medicaid
CA3636OtherMEDICAL EYE SERVICES INS
CA3636OtherMEDICAL EYE SERVICES INS
T10700Medicare UPIN