Provider Demographics
NPI:1801881016
Name:KINZEY, RICKEY DALE (DO)
Entity type:Individual
Prefix:
First Name:RICKEY
Middle Name:DALE
Last Name:KINZEY
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 MARKET ST STE 101
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47111-9535
Mailing Address - Country:US
Mailing Address - Phone:812-503-5100
Mailing Address - Fax:770-573-9513
Practice Address - Street 1:400 MANN ST STE 107
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78401-2046
Practice Address - Country:US
Practice Address - Phone:361-533-9911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000860A207LP2900X, 207Q00000X
TXT1985207QA0401X, 207RA0401X, 207L00000X
261QM0801X
IN02000860C207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100446040Medicaid
TX434219808Medicaid
IN000000368845OtherRKP ANTHEM
IN000000368855OtherRKA ANTHEM
IN000000368845OtherRKP ANTHEM
IN547260UMedicare PIN