Provider Demographics
NPI:1992711071
Name:TICHO, GABRIEL (MD)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:TICHO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LAKE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-6785
Mailing Address - Country:US
Mailing Address - Phone:715-848-4600
Mailing Address - Fax:715-845-5398
Practice Address - Street 1:1100 LAKE VIEW DR
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-6785
Practice Address - Country:US
Practice Address - Phone:715-848-4600
Practice Address - Fax:715-845-5398
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32157-0202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31706300Medicaid
WI31706300Medicaid