MEDICARE: DR. DWIGHT ROBERT RICKETTS D.P.M.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	P0298	DC

General Provider Information

NPI Number	:	1083751507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DWIGHT ROBERT RICKETTS D.P.M.

Provider Business Mailing Address
First Line	:	7826 EASTERN AVE NW
Second Line	:	SUITE 209
City	:	WASHINGTON
State	:	DC
Zip	:	20012-1324
Country	:	US
Telephone Number	:	202-722-2997
Fax Number	:	202-722-2997

Provider Business Practice Location Address
First Line	:	7826 EASTERN AVE NW
Second Line	:	SUITE 209
City	:	WASHINGTON
State	:	DC
Zip	:	20012-1324
Country	:	US
Telephone Number	:	202-722-2997
Fax Number	:	202-722-2997

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	07/08/2007

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