Provider Demographics
NPI:1447293675
Name:NICKLOES, TODD A (DO)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:A
Last Name:NICKLOES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1932 ALCOA HWY
Mailing Address - Street 2:STE 270
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-1527
Mailing Address - Country:US
Mailing Address - Phone:865-251-4658
Mailing Address - Fax:865-251-4659
Practice Address - Street 1:1932 ALCOA HWY
Practice Address - Street 2:STE 270
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1527
Practice Address - Country:US
Practice Address - Phone:865-544-9433
Practice Address - Fax:865-544-8688
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO00000013272086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3306124Medicaid
TN3306124Medicare ID - Type Unspecified