Provider Demographics
NPI:1174260715
Name:TICKNOR, STEVEN (OD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:
Last Name:TICKNOR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:568 WOODCREST DR
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-1525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3621 MARKET LN
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1553
Practice Address - Country:US
Practice Address - Phone:262-658-8119
Practice Address - Fax:262-658-8261
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-16
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3810-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist