MEDICARE: DR. DWAIN WILLIAM RICKERTSEN M.D.

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	207Q00000X	Family Medicine Physician	A450730	CA

General Provider Information

NPI Number	:	1619165925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DWAIN WILLIAM RICKERTSEN M.D.

Provider Business Mailing Address
First Line	:	PO BOX 939
Second Line	:
City	:	ANGELS CAMP
State	:	CA
Zip	:	95222-0939
Country	:	US
Telephone Number	:	209-754-6262
Fax Number	:	209-736-1814

Provider Business Practice Location Address
First Line	:	1233 PLUMAS ST
Second Line	:	SUITE A
City	:	YUBA CITY
State	:	CA
Zip	:	95991-3410
Country	:	US
Telephone Number	:	530-671-2020
Fax Number	:	530-671-6797

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

Provider Enumeration Date	:	10/11/2007
Last Update Date	:	12/27/2018

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