Individual
TIMOTHY BOCK ICENOGLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
4403 HARRISON BLVD STE 3835, OGDEN, UT 84403-3331
(801) 387-3475
(801) 387-3480
Mailing address
PO BOX 27128, SALT LAKE CITY, UT 84127-0128
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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