Provider Demographics
NPI:1699954602
Name:RICKETTS, ROBERT MASON JR (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MASON
Last Name:RICKETTS
Suffix:JR
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 1:1011 BALTIMORE BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-7055
Mailing Address - Country:US
Mailing Address - Phone:410-469-5001
Mailing Address - Fax:
Practice Address - Street 1:1011 BALTIMORE BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-7055
Practice Address - Country:US
Practice Address - Phone:410-469-5001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-25
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0039296174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD066921102Medicaid
MDC34425Medicare UPIN
MD066921102Medicaid