Provider Demographics
NPI:1285683029
Name:ICENOGLE, TIMOTHY BOCK (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:BOCK
Last Name:ICENOGLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4403 HARRISON BLVD STE 3835
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3331
Practice Address - Country:US
Practice Address - Phone:801-387-3475
Practice Address - Fax:801-387-3480
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00026659204F00000X, 208G00000X
TXS9004208G00000X
UT126770044-1205208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1072495Medicaid
ID3756900Medicaid
MT3505645Medicaid
WAG8923014Medicare PIN
WA1072495Medicaid
WAG000302401Medicare PIN