Basic Information
| Provider Information | |||||||||
| NPI: | 1689601338 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VIATOR | ||||||||
| FirstName: | RICKEY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2699 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325132699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504754500 | ||||||||
| FaxNumber: | 8504754619 | ||||||||
| Practice Location | |||||||||
| Address1: | 23 MACK BAYOU LOOP | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SANTA ROSA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324592604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502783920 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 03/17/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME45069 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 09135 | 01 | FL | BCBS | OTHER | 061248100 | 05 | FL | MEDICAID | 101554 | 01 | FL | AVMED | OTHER | P00379114 | 01 | FL | RAILROAD MEDICARE | OTHER |