Provider Demographics
NPI:1366402125
Name:SIEWERT, RICKY ALLEN (DO)
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:ALLEN
Last Name:SIEWERT
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 1:3006 GARRETT DR
Mailing Address - Street 2:
Mailing Address - City:PERRYTON
Mailing Address - State:TX
Mailing Address - Zip Code:79070-5322
Mailing Address - Country:US
Mailing Address - Phone:806-435-9626
Mailing Address - Fax:806-435-4175
Practice Address - Street 1:3006 GARRETT DR
Practice Address - Street 2:
Practice Address - City:PERRYTON
Practice Address - State:TX
Practice Address - Zip Code:79070-5322
Practice Address - Country:US
Practice Address - Phone:806-435-9626
Practice Address - Fax:806-435-4175
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDOG2576207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137858004Medicaid
TX137858004Medicaid
TX00J44HMedicare PIN
TXSX88Medicare ID - Type Unspecified