Provider Demographics
NPI:1245255686
Name:BURK, RICKY R (OD)
Entity type:Individual
Prefix:DR
First Name:RICKY
Middle Name:R
Last Name:BURK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1506
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0409
Mailing Address - Country:US
Mailing Address - Phone:360-242-3008
Mailing Address - Fax:360-807-7687
Practice Address - Street 1:19801 SW 72ND AVE STE 150
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8347
Practice Address - Country:US
Practice Address - Phone:503-691-2283
Practice Address - Fax:503-691-5981
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORATI2559152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1245255686Medicaid
WA410031430OtherRAIL ROAD MEDICARE
WA410031420OtherRAIL ROAD MEDICARE
OR410031421OtherRAIL ROAD MEDICARE
ID410031424OtherRAIL ROAD MEDICARE
WA410031425OtherRAILROAD MEDICARE
ID410031427OtherRAIL ROAD MEDICARE
AK410045000OtherRAIL ROAD MEDICARE
WA410031423OtherRAIL ROAD MEDICARE
WA2019370Medicaid
OR209408Medicaid
WA410031428OtherRAIL ROAD MEDICARE
AK1023231Medicaid
WA410031429OtherRAIL ROAD MEDICARE
ID410031424OtherRAIL ROAD MEDICARE
WA410031425OtherRAILROAD MEDICARE
WA410031423OtherRAIL ROAD MEDICARE
WA410031430OtherRAIL ROAD MEDICARE
WA410031428OtherRAIL ROAD MEDICARE
ID410031427OtherRAIL ROAD MEDICARE