Provider Demographics
NPI:1285715110
Name:RICKWARTZ, KEVIN (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:RICKWARTZ
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:PO BOX 24691
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76124-1691
Mailing Address - Country:US
Mailing Address - Phone:817-451-4208
Mailing Address - Fax:
Practice Address - Street 1:1501 S COULTER ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1770
Practice Address - Country:US
Practice Address - Phone:806-354-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9646207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX037648501Medicaid
NM68773889Medicaid
OK200033600AMedicaid
TX81125SOtherBLUE CROSS & BLUE SHIELD
TX930093588Medicare PIN
NM68773889Medicaid
TX8080K1Medicare PIN