Basic Information
Provider Information | |||||||||
NPI: | 1881603017 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RANKIN | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RANKIN | ||||||||
OtherFirstName: | BRANDON | ||||||||
OtherMiddleName: | R. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: | III | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 15498 | ||||||||
Address2: |   | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 95857 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5594554000 | ||||||||
FaxNumber: | 5594554007 | ||||||||
Practice Location | |||||||||
Address1: | 1121 W VINE STREET | ||||||||
Address2: | SUITE 15 | ||||||||
City: | LODI | ||||||||
State: | CA | ||||||||
PostalCode: | 95240 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2093344416 | ||||||||
FaxNumber: | 2093710119 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2006 | ||||||||
LastUpdateDate: | 10/26/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | G54313 | CA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 00G543130 | 05 | CA |   | MEDICAID |