Provider Demographics
NPI:1558627794
Name:LYCAN, THOMAS WILLIAM JR (DO)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WILLIAM
Last Name:LYCAN
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:WAKE FOREST MEDICAL CENTER
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:WAKE FOREST MEDICAL CENTER
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157
Practice Address - Country:US
Practice Address - Phone:336-716-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-02
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2018-01240207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program