Provider Demographics
NPI:1982763231
Name:TICHAUER, CORY SEAN (ND)
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:SEAN
Last Name:TICHAUER
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7027
Mailing Address - Country:US
Mailing Address - Phone:541-770-5563
Mailing Address - Fax:541-772-3028
Practice Address - Street 1:1012 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7027
Practice Address - Country:US
Practice Address - Phone:541-770-5563
Practice Address - Fax:541-772-3028
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1324175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR029098Medicaid
OR865304002OtherBLUE CROSS BLUE SHIELD