Provider Demographics
NPI:1528061264
Name:WILKERSON, RICKY DUANE (DO)
Entity type:Individual
Prefix:DR
First Name:RICKY
Middle Name:DUANE
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-2325
Mailing Address - Country:US
Mailing Address - Phone:563-382-2911
Mailing Address - Fax:563-382-4143
Practice Address - Street 1:901 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101
Practice Address - Country:US
Practice Address - Phone:563-382-2911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-26
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN66249207X00000X
IADO-02193207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0053397Medicaid
IA0053397Medicaid
IAB85352Medicare UPIN