Provider Demographics
NPI:1164861159
Name:WICAL, TODD A (DO)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:A
Last Name:WICAL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 JOEL DR
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5318
Mailing Address - Country:US
Mailing Address - Phone:270-412-1411
Mailing Address - Fax:270-412-6802
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:270-412-1411
Practice Address - Fax:270-412-6802
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-23
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY04424207Q00000X
NE1204171000000X, 2083A0100X, 207Q00000X
TN3503207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine