Provider Demographics
NPI:1932218047
Name:RICKETTS, JAMES M (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:RICKETTS
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 1:1347 TAVERN RD
Mailing Address - Street 2:STE 9
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-3853
Mailing Address - Country:US
Mailing Address - Phone:619-445-0204
Mailing Address - Fax:619-659-0205
Practice Address - Street 1:1347 TAVERN RD
Practice Address - Street 2:STE 9
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-3853
Practice Address - Country:US
Practice Address - Phone:619-445-0204
Practice Address - Fax:619-659-0205
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4384207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ48102ZOtherBLUE SHIELD
CA00AX43840Medicaid
CAZZZ48102ZOtherBLUE SHIELD
CAW20A4384AMedicare ID - Type Unspecified