Healthcare Provider Details

I. General information

NPI: 1700926862
Provider Name (Legal Business Name): DAVID J. RICKLES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 02/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14608 HAWTHORNE BLVD
LAWNDALE CA
90260-1521
US

IV. Provider business mailing address

14608 HAWTHORNE BLVD
LAWNDALE CA
90260-1521
US

V. Phone/Fax

Practice location:
  • Phone: 310-978-4970
  • Fax: 310-978-8668
Mailing address:
  • Phone: 951-691-5123
  • Fax: 951-691-5156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberG56693
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: