Provider Demographics
NPI:1477656528
Name:ICKLER, JEFFREY J (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:J
Last Name:ICKLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1700 SPRING HILL AVE
Mailing Address - Street 2:STE 400
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36604-1407
Mailing Address - Country:US
Mailing Address - Phone:251-438-4440
Mailing Address - Fax:251-438-4599
Practice Address - Street 1:1700 SPRING HILL AVE
Practice Address - Street 2:STE 400
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-1407
Practice Address - Country:US
Practice Address - Phone:251-438-4440
Practice Address - Fax:251-438-4599
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2011-04-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AL00022258208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009998120Medicaid
AL009998120Medicaid