Provider Demographics
NPI:1982630703
Name:VANSICKLE, JODI L (MD)
Entity Type:Individual
Prefix:DR
First Name:JODI
Middle Name:L
Last Name:VANSICKLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 KIMBALL AVE
Mailing Address - Street 2:LL14
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5063
Mailing Address - Country:US
Mailing Address - Phone:319-272-1590
Mailing Address - Fax:319-272-1535
Practice Address - Street 1:236 NATIONAL DR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-4263
Practice Address - Country:US
Practice Address - Phone:319-272-0000
Practice Address - Fax:319-272-0016
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA31864208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1159111Medicaid
IA1159111Medicaid
IAG57021Medicare UPIN