Basic Information
| Provider Information | |||||||||
| NPI: | 1447293675 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICKLOES | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1932 ALCOA HWY | ||||||||
| Address2: | STE 270 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379201527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652514658 | ||||||||
| FaxNumber: | 8652514659 | ||||||||
| Practice Location | |||||||||
| Address1: | 1932 ALCOA HWY | ||||||||
| Address2: | STE 270 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379201527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655449433 | ||||||||
| FaxNumber: | 8655448688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 04/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0127X | DO0000001327 | TN | Y | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3306124 | 05 | TN | MEDICAID |