Healthcare Provider Details

I. General information

NPI: 1710968979
Provider Name (Legal Business Name): JOHN RICKETSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 11/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 N MONROE ST
ALBANY GA
31701-1903
US

IV. Provider business mailing address

1001 N MONROE ST
ALBANY GA
31701-1903
US

V. Phone/Fax

Practice location:
  • Phone: 229-436-7248
  • Fax: 229-431-1951
Mailing address:
  • Phone: 229-436-7248
  • Fax: 229-431-1951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number23099
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: