Provider Demographics
NPI:1043915424
Name:RICKETTS, CLEVELAND SAMUEL (MD)
Entity type:Individual
Prefix:
First Name:CLEVELAND
Middle Name:SAMUEL
Last Name:RICKETTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 LAUGHLIN
Mailing Address - Street 2:
Mailing Address - City:EAST STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614
Mailing Address - Country:US
Mailing Address - Phone:203-684-3143
Mailing Address - Fax:
Practice Address - Street 1:330 BROOKLINE AVENUE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-667-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2025-08-11
Deactivation Date:2023-11-09
Deactivation Code:
Reactivation Date:2025-08-11
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program