MEDICARE: DR. WILLIBROAD W TICHA PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343900000X	Non-emergency Medical Transport (VAN)
2	343800000X	Secured Medical Transport (VAN)		TX

General Provider Information

NPI Number	:	1225601354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIBROAD W TICHA PHD

Provider Business Mailing Address
First Line	:	9600 GOLF LAKES TRAIL
Second Line	:	1007
City	:	DALLAS
State	:	TX
Zip	:	75231
Country	:	US
Telephone Number	:	202-294-8080
Fax Number	:

Provider Business Practice Location Address
First Line	:	9600 GOLF LAKES TRAIL
Second Line	:	1007
City	:	DALLAS
State	:	TX
Zip	:	75231
Country	:	US
Telephone Number	:	202-294-8080
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2021
Last Update Date	:	10/04/2023

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