Provider Demographics
NPI:1093709750
Name:BICKEL, JASON R (DPM)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:BICKEL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 E SAINT CLAIR ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-4853
Mailing Address - Country:US
Mailing Address - Phone:812-885-3325
Mailing Address - Fax:812-885-8499
Practice Address - Street 1:202 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1228
Practice Address - Country:US
Practice Address - Phone:812-882-3312
Practice Address - Fax:812-882-6181
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN599174400000X
IN07001040A213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No174400000XOther Service ProvidersSpecialist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000542568OtherANTHEM
IL000000542574OtherANTHEM
IN200879590AMedicaid
IL000000542574OtherANTHEM
P00447893Medicare PIN
TNV00625Medicare UPIN
IN254060AMedicare PIN