Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 895-025 | WI |
Y | 222Z00000X | Podiatrist | 895-025 | WI |
NPI | 1073500526 |
---|---|
Provider Name | Dr. Joel J Tikalsky |
First Address | Weston, WI 54476-6421 |
Second Address | Weston, WI 54476-6421 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/09/2005 |
Last Update Date | 18/03/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
V04208 | (02) | WI |