Provider Demographics
NPI:1518074624
Name:TYLICKI, DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:TYLICKI
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 1:915 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-3994
Mailing Address - Country:US
Mailing Address - Phone:262-569-2300
Mailing Address - Fax:
Practice Address - Street 1:915 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3994
Practice Address - Country:US
Practice Address - Phone:262-569-2300
Practice Address - Fax:262-569-2266
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003014015208100000X
WI45027208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34679900Medicaid