Provider Demographics
NPI:1750607388
Name:RICO, CARLOS LUIS (DO)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:LUIS
Last Name:RICO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 N COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:OH
Mailing Address - Zip Code:44827-1455
Mailing Address - Country:US
Mailing Address - Phone:419-462-3485
Mailing Address - Fax:
Practice Address - Street 1:5100 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-1607
Practice Address - Country:US
Practice Address - Phone:614-544-2089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-07
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34011306207QA0401X, 207Q00000X, 208D00000X
OH34-011306207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice