Provider Demographics
NPI:1255727905
Name:RICKS, CHRISTOPHER (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:RICKS
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 1:1735 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1010
Mailing Address - Country:US
Mailing Address - Phone:801-374-1818
Mailing Address - Fax:
Practice Address - Street 1:1735 N STATE ST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1010
Practice Address - Country:US
Practice Address - Phone:801-374-1818
Practice Address - Fax:801-374-0163
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1014225-1205207W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1255727905Medicaid