Provider Demographics
NPI:1801892898
Name:RETTELE, GARRICK A (MD)
Entity type:Individual
Prefix:DR
First Name:GARRICK
Middle Name:A
Last Name:RETTELE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1411 W 4TH ST
Mailing Address - Street 2:STE D
Mailing Address - City:COFFEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67337-3300
Mailing Address - Country:US
Mailing Address - Phone:620-251-3235
Mailing Address - Fax:620-251-3252
Practice Address - Street 1:1411 W 4TH ST
Practice Address - Street 2:STE D
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-3300
Practice Address - Country:US
Practice Address - Phone:620-251-3235
Practice Address - Fax:620-251-3252
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS04-26308207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS041849OtherBCBS OF KS
KS100190920AMedicaid
KS100190920AMedicaid
KSG20987Medicare UPIN
KS041849Medicare ID - Type Unspecified