Provider Demographics
NPI:1104788595
Name:RICKETT, MALLORY MICHELLE (OD)
Entity type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:MICHELLE
Last Name:RICKETT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23010 JANE RD
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77377-3700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:655 TAYLOR ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-4821
Practice Address - Country:US
Practice Address - Phone:817-289-6825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-24
Last Update Date:2025-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11387TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist