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Individual
TIMOTHY BOCK ICENOGLE
Active
Individual
TIMOTHY BOCK ICENOGLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Taxonomy
Speciality
Code
Description
License number
State
204F00000X
Transplant Surgery Physician
MD00026659
WA
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
Primary
126770044-1205
UT
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
MD00026659
WA
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
S9004
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1072495
—
WA
05
—
3505645
—
MT
05
—
3756900
—
ID
Enumeration date
05/09/2006
Last updated
12/13/2022
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