Basic Information
| Provider Information | |||||||||
| NPI: | 1538133830 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICKS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1736 LATTA CT | ||||||||
| Address2: | |||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321622203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522591180 | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 E DIXIE AVE | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347485925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523235200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 10/31/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 36335 | MA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | ME86795 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 273774400 | 05 | FL | MEDICAID | 30238 | 01 | FL | BCBS | OTHER | P00290006 | 01 | RAILROAD | OTHER |