Provider Demographics
NPI:1821099615
Name:TICORAS, CHRIST JOHN (MD)
Entity Type:Individual
Prefix:
First Name:CHRIST
Middle Name:JOHN
Last Name:TICORAS
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 1:770 BALGREEN DR
Mailing Address - Street 2:STE 201
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-4106
Mailing Address - Country:US
Mailing Address - Phone:419-756-1600
Mailing Address - Fax:419-775-1196
Practice Address - Street 1:770 BALGREEN DR
Practice Address - Street 2:STE 201
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-4106
Practice Address - Country:US
Practice Address - Phone:419-756-1600
Practice Address - Fax:419-775-1196
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-3717T207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000199905OtherBCBS
OH2146574Medicaid
OH000000199905OtherBCBS
OH070015703Medicare PIN
OH000000199905OtherBCBS
OH2146574Medicaid