Provider Demographics
NPI:1881957769
Name:WILSON, RICKESHA LANEE' (MD)
Entity type:Individual
Prefix:DR
First Name:RICKESHA
Middle Name:LANEE'
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 SUPERIOR AVE E APT 402
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-1421
Mailing Address - Country:US
Mailing Address - Phone:682-365-1211
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE # M61
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:682-365-1211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-16
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.138778208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program