Provider Demographics
NPI:1881747806
Name:KEVIN M. RICCITELLI, D.O. LLC.
Entity type:Organization
Organization Name:KEVIN M. RICCITELLI, D.O. LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:RICCITELLI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-248-1199
Mailing Address - Street 1:916 SW 38TH ST
Mailing Address - Street 2:SUITE D.
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-7005
Mailing Address - Country:US
Mailing Address - Phone:580-248-1199
Mailing Address - Fax:580-248-3679
Practice Address - Street 1:916 SW 38TH ST
Practice Address - Street 2:SUITE D.
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-7005
Practice Address - Country:US
Practice Address - Phone:580-248-1199
Practice Address - Fax:580-248-3679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-21
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2220207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKD60729Medicare UPIN