Healthcare Provider Details

I. General information

NPI: 1477656528
Provider Name (Legal Business Name): JEFFREY J ICKLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10241 BONEY AVE STE A
DIBERVILLE MS
39540-4889
US

IV. Provider business mailing address

10241 BONEY AVE STE A
DIBERVILLE MS
39540-4889
US

V. Phone/Fax

Practice location:
  • Phone: 228-967-7651
  • Fax: 228-967-7653
Mailing address:
  • Phone: 228-967-7651
  • Fax: 228-967-7653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number00022258
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: