Healthcare Provider Details

I. General information

NPI: 1750607388
Provider Name (Legal Business Name): CARLOS LUIS RICO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 06/12/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 NORTH OAK AVENUE
MARSHFIELD WI
54449-5703
US

IV. Provider business mailing address

700 N COLUMBUS ST
CRESTLINE OH
44827-1455
US

V. Phone/Fax

Practice location:
  • Phone: 715-387-5511
  • Fax:
Mailing address:
  • Phone: 419-462-3485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number34-011306
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34011306
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number34011306
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number34011306
License Number StateOH
# 5
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number13083
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: