Provider Demographics
NPI:1548291263
Name:RICKS, MARVIN DARYLE (DPM)
Entity type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:DARYLE
Last Name:RICKS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 MCHENRY VILLAGE WAY STE 3
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4338
Mailing Address - Country:US
Mailing Address - Phone:209-526-3907
Mailing Address - Fax:209-526-3908
Practice Address - Street 1:1601 MCHENRY VILLAGE WAY STE 3
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4338
Practice Address - Country:US
Practice Address - Phone:209-526-3907
Practice Address - Fax:209-526-3908
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2454213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E24540Medicaid
CA000E24541Medicaid
CA000E24540Medicaid
CA000E24540Medicare ID - Type Unspecified
CAT11338Medicare UPIN