Provider Demographics
NPI:1588694012
Name:WILSON, RICKEY L (MD)
Entity type:Individual
Prefix:
First Name:RICKEY
Middle Name:L
Last Name:WILSON
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 1:1401 W CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804-1707
Mailing Address - Country:US
Mailing Address - Phone:563-421-1785
Mailing Address - Fax:563-421-2918
Practice Address - Street 1:1401 W CENTRAL PARK AVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-1707
Practice Address - Country:US
Practice Address - Phone:563-421-1785
Practice Address - Fax:563-421-2918
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034948A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
11196050OtherCAQH
000000351695OtherANTHEM
11196050OtherCAQH